Category — Ask Dr. R.

Dear Dr. I was reading an article in the glamour magazine and came across your name. I’m 38 years old. I’ve two kids (5, 3) and married for 6 years. During these years, I had orgasm only one time with my husband. I have other problems going on in life too. But part of the reason is that my husband can tell that I don’t have orgasms. I never had sex before so when I got married at the age of 30, you could tell I was lost. My marriage is in the verge of breaking up. I used machine (rabbit) and it works. I just don’t understand why it won’t work with my husband. He said every girl he had sex before had orgasms, except for me. I do know that he doesn’t foreplay, all he wants is sex. And I don’t enjoy it like that. He knows that women like cuddling but still he won’t do that to me. What can I do? How can I improve myself?

Hello Distressed,
Many women (most women) need foreplay to fully enjoy sex and to achieve orgasm. Your husband’s premarital record of routine female orgasms without foreplay is remarkable, unusual and almost unbelievable.
Your relationship would benefit from couples counseling with a board certified psychiatrist or psychologist specializing in sexual function.
This is not a problem about YOU. It is a problem about your relationship and conflicting expectations between yourself and your husband. If your husband won’t go, you will benefit from going alone.
Best Regards,
Dr R

I urge you all to check out the entire content on Women’s Voices for Change, an online resource for grown women and the people who love them.

Betty, a woman with uterine prolapse, recently wrote in to this blog, asking advice after her doctor told her she would need a hysterectomy to fix her prolapse. We now understand that the mechanics of prolapse are all about those ligaments, and that the uterus, literally, contributes nothing to prolapse other than it’s change in position from “up there” to “out there”.  Dr. Pat Allen, Gynecologist extraordinaire and founder of Women’s Voices for Change, called me in to pinch hit on this one, and with bases full, Dr. R goes to bat:

Dear Betty,

You’ve done a great job of describing a condition that many women are intimately familiar with and, like you, embarrassed to talk about. I asked WVFC Medical Advisory Board member Lauri Romanzi, M.D., a specialist in reconstructive pelvic surgery and urogynecology, to respond. Which she did, pulling out a drawerful of medical illustrations to help explain what’s going on in your body, and why a hysterectomy isn’t the answer. —Dr. Pat

Betty’s Prolapse Problem

I recently read an article you were featured in for Glamour magazine and sparked me to find out more about your practice.  I am a 25 y/o female in a committed, sexual active relationship.  With past partners I have experienced vaginal pain during intercourse and this partner is no exception.  No matter how much foreplay, lubrication, positions, etc we try, I still experience pain.  I want to be able to enjoy sex with my boyfriend, but it’s hard to do when it is physically painful every time.  Help!

 Dear Glamour reader,

Your symptoms can be treated – the trick is to figure out how many issues are contributing, and how best to formulate your personal recipe for successful resolution of your sexual pain. For instance, if stiff levator (Kegel) muscles are part of the problem, it is important to figure out if the muscles are the cause of your symptoms, or if the muscles are stiff and sore because of another source of pain in or around the vagina that also hurts, with the muscles reacting to the pain and then themselves becoming a secondary source of pain. Confused yet?

You may have vestibulitis, you may have vaginismus, you may have a urethral diverticulum, you may have yet another urogynecologic condition contributing to your pain. The key to successful treatment is evaluation and management by the right team, which may include a gynecologist who specializes in vestibulitis, a urogynecologist, a pain management anesthesiologist, and a pelvic floor physical therapist.

If you’re in a large metropolitan area, this mix of clinicians will be easy to find, time consuming, but easy. If you are in an area without a lot of specialists, you may need to travel to get the care that you need to put your pelvic life on a normal track.

Most importantly, it is NOT in your head. (It’s in your vagina) Be tenacious. Screen the offices over the phone with questions like “Does Dr. XYZ take care of patients with sexual pain, vestibulitis, levator hypertonus and vaginismus?” If the answer is yes, GO THERE.

Thanks for sharing your story.  Please keep us posted.

Dr R

i need your help. i have problems with fistula, thank you. I am from Kosova.

Hello Kosova,
Fistula is a terrible problem. You will be best served at a University-based medical clinic in urogynecology, urology or colorectal surgery. If you are able to travel to New York, please notify us at contact@urogynics.org or by calling 0012129354343.  Please keep in touch.

Dr Romanzi

Dr. Romanzi, 19 years ago I gave birth to my daughter, and while she was being delivered I was torn from my vaginal opening to my anus. The Dr. didn’t repair the torn skin correctly, and I am very self conscious about this. I also have a very hard time wipeing my BM all the way. Is their anything that can be done for this?

Thank K

Dear K,
Even with correct technique at the time of delivery these deep tears often don’t heal perfectly due to the swelling and hormonal changes in skin and deep connective tissues during pregnancy and delivery that result in less than optimal healing from childbirth tears. That said, it is very likely that your anatomy and function can be restored or significantly improved with reconstructive surgical repair of the perineum (perineoplasty) and/or anal sphincter (anal sphincteroplasty). Sometimes perineoplasty alone is enough. Whether one or both procedures might be advised can only be determined through clinical examination, after which various other imaging and colorectal tests might be advised to determine the optimal procedure(s) for your personal situation. It’s been 19 years! Pull this up to the top of your priority list and get the information you need. Thanks for sharing your story. Please keep us posted!

Dr R

Dear Dr. Romanzi,
I recently finished your book and found it quite informative. I had my first baby when I was 35, pitocin-induced with no pain medication. After a short but extremely intense labor, my labia tore off and although the doctor tried to repair it, it doesn’t feel (or look) quite right and seems to flap open all the time. I also feel like my vagina is a wind tunnel, especially when I do yoga–it makes a lot of noises. Ever since the birth I have suffered from stress incontinence but I’m not sure if I have prolapse. Several doctors have told me I am too young for a sling or surgery and simply recommended kegel exercises. I’ve tried kegels and even got the Myself (a biofeedback system) and nothing has improved my incontinence. I am now 38 and 20 weeks pregnant (not planning any other pregnancies). How soon I can get these issues fixed after I deliver? Do you think I am too young for a sling?

Dear Reader,
No one is “too young for a sling”, provided they suffer significant stress urinary incontinence. Two categories of incontinence apply to most women with bladder control problems, those being stress (”exert and squirt” leaking with cough, sneeze, lift, running, etc) and urge (overactive bladder, urination before seated on toilet), and about 1/3 of women with incontinence have a little of both problems.
Kegels are a good therapy for both types of incontinence in about 70% of cases, including mixed stress/urge. Once you’ve birthed the baby, you may be well served to spend 12 weeks working properly wtih a pelvic floor physical therapist rather than on your own with or without a Kegel exercise gadget. It’s like working with a personal trainer, typically yielding better results. If this fails, you may need medications or electric stimulation for urge incontinence, and a sling for stress incontinence. Slings do not reliably improve urge incontinence, an important distinction should a sling be recommended for you – it is likely that overactive bladder symptoms will persist after a sling, with the “exert and squirt” symptoms gone, or significantly reduced.
The vaginal laxity may also respond to Kegel exercise because the exercises can bulk up the vaginal muscles, making for snugger inner contour. If this does not work, reconstructive surgery may be done with or without concomitant sling, and your labum can be repaired at the same time. The exact best procedure for you, however, can only be determined with a proper pelvic support examination and bladder function testing.
Typically, women are advised to complete childbearing before undergoing reconstructive surgery for laxity, prolapse and stress incontinence, since pregnancy after said operation(s) may undo the results.
Thank you for sharing you story!
Best Regards, Dr R

Dr. R, I wrote to you about a month ago. I did decide to go ahead and have the Laproscopic Bilateral(other part of hysterectomy) done. I had the partial in 2000. I had it done one week ago today. I am feeling much better. Little pain in the navel area. Some “hot flashes” ocurring in the early hours of the morning for a few minutes and then they go away. My doctor said that the surgery went well and I am to follow-up with him in about 3 weeks. Dr. R, I hear some women say that they lost their drive for sexual intercourse. Does this happen in all women who have total hysterectomies or does it depend on the female. I am a little nervous about this. I have been married 18 1/2 years and my husband is a wonderful man. What advice do you have now that all my plumbing is gone. Thanks for your previous response to my question in April. I really love your website. God Bless R (Alabama)

Dear R from Alabama,
We are learning more every day about women’s sexuality, and we have found that a variety of hormones definitely contribute to sex drive. Some of these hormones are produced by the ovary, while others come from the adrenal glands (on top of your kidneys) and others come from your brain. Chances are your sex drive will be just fine, possibly better now that the source of pelvic pain is gone, along with the worry. The love and stability in your relationship trumps all, as this is the sexiest of sex drive factors.
Thank you for getting back to us and sharing your story.
Dr. R

Dear Dr. Romanzi,
(I bet you don’t get too many men writing you for help!) My dearest sweetheart suffers from a prolapsed uterus/bladder and is considering having a hysterectomy at the advice of her gyno. Being a former pre-med student and having seen what my mother and sister-in-law went through in their hysterectomies (cancer related…) I keep trying to convince her that this a radical surgical approach for a problem that demands far less. She has had 2 children, is 52 years old and is physically active. However, “the bulge” is causing her discomfort in her exercising and she is talking more and more of the hysterectomy. I am ordering your book tonight, but in the meantime had some questions… 1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work? 2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery, and 3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure. If the former, what does it typically cost? She is a women of limited means and this obviously comes into the equation. Thanks so much for your help. D

Hello D,

Thank you for writing in – I know there are more men out there trying to help the women they love, and your willingness to post your questions will undoubtedly help other men actively advocate for the health of the women in the lives.
1) Since she is past her childbearing years, is reconstructive surgery appropriate, or could a pessary work?
She may do perfectly well with a pessary and I often advise pessary use before any other therapies are considered. But some women cannot be fit with comfortable pessary or a pessary that truly holds it all in due to the severity of prolapse (the worse the prolapse the more difficult to find a well fitting comfortable pessary) or idiosyncracies in the boney pelvis that make pessaries uncomfortable, in which case the next option is reconstructive surgery. Some women may be fitted for a pessary that works perfectly well, but they find it annoying or “unsexy” to use, in which case it may be worn until she has time to undergo reconstructive surgery and it’s recuperation (~4 weeks to return to work, 6-8 week til sex is possible). Pessaries that fit well physically and jive with lifestyle and body image provide an excellent non-surgical therapy for prolapse.
2) We are from Cincinnati, OH. I went to the AUGS website to try and find providers in our area, but I wasn’t sure if these are just gynecologists or OB’s who perform reconstructive surgery,
The major university medical centers all have urogynecology divisions run by fellowship trained specialists – these are a good place to start. You may want to obtain several opinions should you choose reconstructive surgery.
3) Is the reconstructive approach treated as “cosmetic” surgery from an insurance perspective, or is it usually a covered procedure
Prolapse surgery is the same as any other reconstructive surgery, be it a hernia, a knee repair or a rotator cuff repair. While not an emergency, it is a recognized condition that insurance companies do not consider cosmetic.
Finally, hysterectomy does not improve the durability of prolapse surgery, and she DOES NOT need a hysterectomy to benefit from excellent long term (hopefully life-long) results should she choose to undergo reconstructive pelvic surgery. Recurrence is possible with any and all reconstructive operations done anywhere in the body by any technique, and prolapse repair is prone to recurrence in the same way hernias may recur and damaged knee ligaments may not last forever after knee surgery. Reconstructive surgery puts things back together, unlike extirpative surgery that takes things out – appendix out, guaranteed you’ll never have to have it removed again! Hernia surgery – might need another one someday.
In order to help women understand the causes, therapies and surgeries for prolapse, I wrote PLUMBING AND RENOVATIONS as an in-hand resource for women with prolapse and/or incontinence (www.plumbingandrenovations.com). She may find this book a helpful guide as the therapeutic options are considered. Thank you for writing in and please do keep us posted.

Best Regards,
DR R