Sexual Health for Women -- Mary Jane Minkin, MD -- 05/15/03

By Mary Jane Minkin
WebMD Live Events Transcript

Sexual health concerns about contraception, menstruation, STDs, and other gynecological issues can affect women from their first periods right through menopause. Ob-gyn Mary Jane Minkin, MD, has covered it all in her book, The Yale Guide to Reproductive Health. She joined us to answer our members' questions on WebMD Live.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to WebMD Live Dr. Minkin. What is the healthiest form of contraceptive? I've heard that getting a shot and taking the pill are both unhealthy. What is the most effective birth control?

Minkin: We could talk probably for one hour on those topics. I think that you have to tie up effectiveness with the word healthy, because if you want perfect effectiveness, nothing's perfect as far as absolute effectiveness, 100%, except for a hysterectomy, and that is extreme.

  • Birth control pills are about 99% effective. In general, they really are quite safe. There is a slight risk of getting a blood clot from the pill, but except for that, they're really pretty safe.

  • The shot form, which is Depo Provera, is 99%-plus effective, and also is quite safe. The major problem with Depo Provera is that it may take a few months to get out of your system and so it may take you a little while to get pregnant after stopping its use. Birth control pills are much more quickly reversible.

  • Barrier methods, such as condoms, are quite safe and also help prevent sexually transmitted infections, but aren't as reliable as far as contraceptive effectiveness. Condoms alone are probably 90% effective, perhaps as much as 95%; condoms combined with contraceptive gels or foams put that effectiveness up towards 97% to 98%. But there is a slight failure rate, and this needs to be taken into account.

  • IUDs are also quite effective, about 98% to 99%, however the major health concern is that they don't protect against sexually transmitted diseases, so if you are at risk in a sexual relationship of passing on an STD or receiving an STD, then an IUD is not safe to use without also using a condom. Similarly for birth control pills, as well.

Member: Can I get pregnant if he ejaculates inside of me the day before I start my period? Can you become pregnant while having sex on your period?

Minkin: The answer, unfortunately, is yes. And the reason is that we are never certain of when ovulation is occurring or when it might occur; sometimes women ovulate very late in their cycle, and sperm can live for a while in the vagina. So although there are "safer times" to have sex, such as right during your period, it's never 100% certain that you would not conceive.

Member: I have three children. All have been C-section. My doctor said it would be very dangerous to have another baby. He has given me two choices: the IUD or to have my tubes tied. Which would be safer?

Minkin: Both choices are quite reasonable. The failure rate of a tubal ligation is about 1 in 200.

The failure rate of the new IUD, the Mirena, is actually pretty close to that, certainly less than 1 in 100. The major advantage that the IUD would have is that you wouldn't have to have surgery to have the IUD inserted, whereas with a tubal ligation, that is a surgical procedure, and given that you've have three cesarean sections, you may have a lot of scar tissue in the belly, which might make the surgery more complex, with risk of damage to bowel or blood vessels.

The other question I would ask you is would your significant other consider a vasectomy? It has an excellent success rate and has no risk of bowel or blood vessel damage to the male.

Member: My husband and I want to get pregnant. I have been off the pill since December and I have a history of ovarian cysts. My periods have been irregular and my doctor suggested taking a blood test to check for ovulation. My results showed no ovulation. Now she is suggesting Clomid. Is it safe? Why am I not ovulating?

Minkin: Excellent question. Many women do not ovulate regularly. There are many conditions that do this, ranging from polycystic ovarian syndrome to stress to exercise to diet changes.

However, Clomid tends to work for all of these. It is a very safe drug. I took it to conceive my second child. There is a slight increased risk of twins with the drug: about 4% to 6%. But it is rare to have more than twins.

I would also like to make sure that you are currently taking a vitamin that contains folic acid every day. That is important for all women trying to conceive.

Member: I am 24, mother of one. I had my son in 2000. When he was 6 months old I stopped having my menstruation. I have seen many doctors and most of them couldn't tell me what might be wrong. One I went to told me I have or had PCOS. But that was in 2002. I started having them again in Jan of 2002 and did all last year. But since March 2003 I haven't had one and the HPT that I have taken come back negative and the ones from the doctor are negative as well. What should I do?

Minkin: If you want to get pregnant at this point, you also would be a good candidate for Clomid. If you just want to check on your hormones, there are several blood tests that would be helpful, including thyroid levels, prolactin, and testosterone levels. But again, if pregnancy is desired, Clomid is a good drug in this situation.

Member: The doctor that I saw that told me I have PCOS put me on Clomid twice and it didn't help. Anything more that I might want to try?

Minkin: You should, in this circumstance, check your prolactin level and thyroid levels, and if they are normal and the Clomid does not work, you would most likely be a good candidate for shots of Pergonal.

Member: Lately when my husband and I have sex I end up with a UTI a few days later. We have been together for over 8 years. What could be the cause of this happening?

Minkin: Sometimes women just start to develop urinary tract infections. One thing that I advise all women to do is to void after intercourse every time. I also encourage women to drink a lot of water. Also, cranberry juice can be very helpful to help prevent urinary tract infections. The most important question I would ask here is, could you possibly be becoming diabetic? I think at least checking your urine for sugar or getting a blood sugar test would be a good idea.

Member: I want to know if it's normal to bleed after having intercourse for the first time? I'm scared; could it be something else?

Minkin: It is very common to bleed after having intercourse the first time. You are probably slightly anxious and probably not well lubricated. Hopefully, by the next time, you will be less anxious and hopefully have had good foreplay to help improve lubrication in the vagina. If not, it is perfectly OK to use a lubricant, like K-Y or Astroglide, which will help with lubrication. The tissue in the vagina is also stretching with first-time intercourse, so there may be some normal bleeding associated with it. If you continue to bleed after intercourse, then it is a good idea to check in with a doctor or nurse midwife for a checkup.

Member: A guy and I have been dating for a while now and are seriously considering marriage. Sex is great and he has been very responsible with our contraception methods. One thing he doesn't understand is that I do not always orgasm. He can't seem to grasp that he can't always "make me happy." How can I better explain to him the reasons why without making things awkward?

Minkin: Many women do not have orgasms all the time with intercourse. What guys don't often understand that that is indeed the case, and that women usually say that they don't have to have orgasm to be content with intercourse every time, that women find that intimacy and being close is more important than the orgasms. I think that you could share this information with him and point out that you are in excellent company; probably at least half, if not all of the women in this chat room have been in a similar situation occasionally, and that he should not feel badly that you don't experience an orgasm 100% of the time.

Member: The last few years I have had abnormal Pap tests. About two years ago I had a colposcopy done. They did not find anything. Now they want me to have another colposcopy done; should I be worried?

Minkin: The first question that I would ask is, what does the most recent Pap test show? If the Pap test is normal, I probably wouldn't do a colposcopy. I would also ask to have an HPV test done as part of the Pap test. If the HPV test, which tests for the papillomaviruses, is negative the situation is most likely fine. If the Pap test is significantly abnormal and the HPV test is positive, I would repeat the colposcopy.

Member: I have a problem with sex. I lost my virginity when I was 23 and it was the worst experience of my life. It hurt. I thought since it was the first time it was normal. So we tried again and the pain was still the same. Two days later I had a very heavy flow of blood. I don't know if that was supposed to be normal. The problem is I've had sex again since then and it's always painful and I get this painful feeling when I go to the bathroom after sex. I have stopped having sex for almost a year now because I don't see the need of having it since all that is felt is pain and not pleasure. Is there something wrong with me? Or is it because I wait long periods of time before I have sex that my vagina shrinks and every time I have sex its like the first time (because that's how it feels). I really wait long periods of time before I have sex -- like months. I've only had sex eight times in a period of three years. Will I ever be able to feel any pleasure when having sex?

Minkin: One question is have you had an internal gynecological checkup, because there could be something going on as far as a band or something around the vagina that is making you uncomfortable. The other possibility as we talked about before, there may be a problem with lubrication, and using a lubricant might be helpful. The other thought I have here is could you be dealing with a condition known as vaginismus, which is a spasm of the vaginal muscles in response to intercourse.

The good news is that it can be treated and a good gynecological exam should help you find out whether you do have some tightening of the muscles as a spasm, or if there something blocking or tightening the vagina, which most likely could be dealt with by a very easy short surgery with anesthesia, or course, so that it wouldn't hurt. So the best thing in this situation would be a good pelvic examination by a nice caring practitioner.

Member: I always have spotting two or three days before periods. Is it normal?

Minkin: It is very common, and oftentimes is associated with not ovulating perfectly. However, I would report it to my caregiver so that at the next examination, she can evaluate it properly with a thorough pelvic exam.

Member: Dr. Minkin I have a question on an STD - ureaplasma. What are the long-term effects if left untreated? My nurse practitioner diagnosed me with this -- gave me/partner Cipro, didn't work, gave doxycycline, didn't work. Are those the only medications that can treat this? The nurse said there is nothing more she can do. Help!

Minkin: Ureaplasma is a controversial organism. It is a cousin of chlamydia. It is not known whether is really does contribute to infertility or not. However, there are a couple of other antibiotics that you might try. I would try either Erythromycin or Zithromax. I'll bet this would work for you, and I think it is worthwhile trying one of them.

Member: So this bacterium does classify as a true STD?

Minkin: As we said, ureaplasma infections are very controversial, as far as whether they are sexually transmitted and if can they be associated with infertility. To be on the safe side I would treat both partners if the woman is infected with ureaplasma, just to be safe, but this is controversial.

In males, if symptomatic, the most common symptom would be a discharge from the penis associated with painful urination. However, men usually do not have symptoms, which is also true for most women, who do not have symptoms either.

Member: I am 20 years old and was just diagnosed with HPV. I have only had one sexual partner, and it has been a very trying time. I am scared because I have a history of cancer in my family, and though I was treated with tricholoroacetic acid (TCA), I fear that my symptoms are recurring. How can I take care of myself in the future to prevent further outbreaks? Can HPV be transmitted orally? How likely is it for a guy to catch it from me? What other health concerns with HPV pose for me? Where do outbreaks occur -- can they show up on the mons pubis, or is it always inside? Does HPV make me more susceptible to other STDs, even while using condoms? I am scared and confused.

Minkin: First of all, the good news is that almost everybody has been infected with HPV at one time or another. That's number one. Number two is that only a small number of the HPV viruses are associated with cancer; most are not. The other good news is that the body is very good at clearing the virus in general. Most people will clear themselves of an infection within a few years without any medication. This, of course, though, is why one should always use a condom in a non-permanent, non-mutually monogamous relationship.

Condyloma viruses can lead to infections in other places besides the vaginal area, and there are many medications, such as Aldara cream that can be used around the vulva, if needed. I would recommend a regular annual Pap test to keep close tabs on your cervix to rule out cancer, but the odds are greatly in your favor that you will be just fine. One also can check that if, indeed, you are carrying the condyloma virus, one can check to see if it is one of the potentially cancer-associated viruses, HPVs, or not. This can be checked at a regular pelvic exam.

Member: I have a question that I can't go to my normal ob-gyn with. I have been in a monogamous relationship (on my side) for eight years. My partner has also had another woman in his life for many years. She has now been diagnosed with stage 4 cervical cancer. I am in late 40s and have annual Pap smears. But so did she and her doctor has said even though she had a Pap smear a year ago her cancer is extremely advanced, something about Pap smears not capturing all or enough cells for proper testing. Am I at risk for cancer?

Minkin: The answer is possibly yes, but not super likely. What I would recommend is you go to your doctor or another doctor and get one of the liquid-based Pap smears done, which would either be the thin prep or autocyte prep Pap, and explain to the doctor why it is very important that you have a very thorough Pap. If this Pap is abnormal, I would recommend that they then do a typing for HPV virus, or human papillomaviruses. If the Pap were normal, I would just continue to go for a regular yearly Pap smear, despite the current recommendations that are now allowing women to have fewer Pap smears. Even if this Pap smear were totally normal, I would encourage you to have a yearly Pap smear for the next few years.

Member: Do I have to worry about STDs if I only have sex with other women? If so, what? And how would I protect myself?

Minkin: This is a very difficult question in that women spreading women STDs to other women is unusual, but possible. The one that you should probably pay most attention to is herpes, because there certainly can be oral transmission of herpes from oral sex. To try to prevent this, one certainly can use things like dental dams, but this is not 100% satisfactory to many women. So I would just recommend that be open with your partner about history of STDs in the past and avoid having relations when anything is active.

Member: Is anal sex is harmful for women or not?

Minkin: Anal sex is not particularly harmful, except if one has anal sex and then proceeds to have vaginal intercourse, because that would then introduce a large amount of bacteria into the vagina. It is OK to start with vaginal intercourse and then proceed to anal intercourse, but not vice-versa. Again, you want to make sure there is plenty of lubrication.

Also, remember that the lining of the anus is more vulnerable to STDs than the vagina even, so anal intercourse is an easy way to spread HIV, for example, and you certainly would want to be using a condom for protection.

Member: My 16-year-old had her first period at 13. One year later she had her second period. So far, she has had a total of seven periods including the first one, and they range from three months to six months apart. Should I be concerned? Pediatrician says to wait until she's 17 before beginning hormones; all blood tests were normal including thyroid. She is healthy. Gynecologist wants her on Provera; I do not know what to do. Any information would be greatly appreciated.

Minkin: First, read my book; we have a section about this in the book. This is not uncommon. The first question I would ask is your daughter exceptionally athletic and participating in a lot of sports, or is she possibly very overweight? In either case, you can see this kind of a pattern. I would agree until the age of 16 or 17 I would not worry about this significantly. If she is very overweight, then I would completely agree with the idea of using Provera to bring about what we call a withdrawal bleed every three months or so. This is to prevent overgrowth of the lining of the uterus.

If she is not overweight, then it probably isn't too important to introduce Provera at this point. If she is very athletic or possibly underweight, then Provera is not super likely to work, and long term you may want to give her both estrogen and progesterone to protect her bones. This also is commonly seen in young women with an eating disorder.

Moderator: Dr. Minkin, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Minkin: First of all I want to thank everyone for being involved with this chat, and I think it is wonderful for women to be concerned about their reproductive health. I think the more women learn and teach their daughters and share with other women the better, and I hope my book will help answer for everyone we didn't get a chance to answer, and I would be delighted to come back and answer more.

Moderator: We are out of time. I'm sorry we couldn't get to all of your great questions. Our thanks to Mary Jane Minkin, MD, and thank you members for joining us today. For more information, please read The Yale Guide to Women's Reproductive Health by Mary Jane Minkin, MD.

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