Surviving the Big C sometimes ain’t so sexy, except of course that you’re alive, which is the sexiest of all. But sometimes, often times, it lets all the air out of your tires when it comes to feeling sexy, being sexy, getting your heart and soul around that Marvin-style Sexual Healing.  A recent study in the American Journal of Obstetrics and Gynecology reports on a need for greater attention paid to the sexual and pelvic floor function of women fortunate enough to survive gynecologic cancers.  If you or someone you love sounds like the women in this study, chances are she’ll find help and hope in the consultation services of a specialist in female sexual dysfunction.

Life ain't for sissies.

Apr 2011 Journal of Sexual Medicine Literature Review

Rutledge TL, Heckman SR, Qualls C, Muller CY, Rogers RG.

Pelvic floor disorders and sexual function in gynecologic cancer survivors: a cohort study.  Am J Obstet Gynecol 2010;203;514E1-7.

This questionnaire survey study used the Pelvic Organ Prolapse/Urinary Incotinenence sexual Questnnaire (PISQ-12) along with validated urinary and fecal incontinence and pelvic organ prolapse questionnaires to determine the prevalence of sexual and pelvic floor disorders in a group of women over age 30 with histories of uterine, cervical, ovarian or vulvar cancer, all disease and treatment free for at least one year.

A control cohort of 108 women without cancer histories also completed the questionnaires after chart review matched them to the study group of cancer survivors. Because the study group was far more likely to have undergone hysterectomy (87% vs 26%) and removal of ovaries (82% vs 14%) than the control group, both of which may independently affect sexual function, data analysis was multivariate.

45% of study participants had history endometrial cancer, 29% ovarian cancer, and 22% cervical cancer. 87% had undergone surgical therapy, 35% radiation, and 35% chemotherapies.  Both groups had rates of urinary incontinence and pelvic organ prolapse that were not statistically significantly different. Women with cancer histories did report higher rates of fecal incontinence and also reported greater fecal incontinence bother than cancer-free controls, despite only 40% of cancer survivors reporting being asked by their oncologists about urinary or incontinence symptoms.

Cancer survivors reported lower libido, higher rates of anorgasmia, lower orgasm intensity, less sexual excitement, lower rates of sexual satisfaction and higher rates of negative emotional response to sexual activity with 5 point lower average PISQ scores and lower rates of sexual activity (45% vs 70%) than the cancer-free cohort. The authors speculate that severe changes in body image and hormone function due as a result of radical pelvic surgery, early withdrawal of natural hormones, hormone suppressive therapies, and radiation effects may all play a role in the extra margin of sexual dysfunction reported by the cancer survivors. The authors state that greater attention to pelvic floor and female sexual dysfunction (FSD) conditions is warranted among clinical oncologists working with female cancer survivors to optimize holistic quality of life issues for these women.

It's different for girls...

Does she or does she not; is the epidemic of “female sexual dysfunction” (FSD) fact or fiction? If fact, what’s to be done about it? Is it hormonal, vascular (clogged arteries – think “atherosclerosis of the vulva and clitoris”), muscular, psychological, or some labyrinthine combination of contributors? Or should we say, detractors? The bad news – we’re not really sure. The good news – smart, skilled & talented people on both sides of the debate care deeply, all carefully plumbing the depths of truth and possibility to sort it all out – to whit:

Apr 2011 Journal of Sexual Medicine Literature Review

NB:    Dypareunia = painful sex    Vaginismus = vaginal muscle spasm often preventing sexual intercourse and always painful

HSDD = Hypoactive Sexual Desire Disorder

Sandhu KS, Melman A, Mikhail MS. Impact of Hormones on Female Sexual Function and Dysfunction. Female Pelvic Med Reconstr Surg 2011;17:8-16.

This review article provides a comprehensive overview of current literature, including areas of controversy, with regard to hormone levels and female sexuality. The authors review the available prevalence data, stating that 43% is the number obtained by the original U. S. National Health and Social Life Survey published in JAMA in 1999 that included women who were, per that author, not necessarily outside of normal range, as the “sexual dysfunctions” included things like fatigue from childcare and housework leading to diminished interest in sex that was not necessarily considered pathological, abnormal or bothersome by the participant women.  Nonetheless, that 43% prevalence rate sparked an avalanche of interest in the possibility that lots of women were suffering sexually without access to evaluation and therapy aside from interactive verbal counseling. These authors respond to the rapid evolution of data sets, therapies and claims by carefully reviewing the formal definitions for the DSM-IV diagnoses of HSDD, categories of female sexual arousal disorders, female orgasmic disorders, dyspareunia and vaginismus, followed by a balanced review of the literature on central and peripheral hormone physiology in menstrual and menopausal women, individual reviews of the roles of estrogen and androgens, the current consensus on normal and abnormal hormone values, the impact of hormone therapies with estrogens and androgens, the impact of natural vs surgical menopause, the controversy regarding androgen insufficiency in pre-menopausal women, and a summary table of Conclusions and Recommendations generated by the Female Sexual Dysfunction Committee in 2004. The authors finish by reviewing practical aspects of current therapies for female sexual dysfunction including phosphodiesterase inhibitors,  Tibolone, DHEA, mechanical devices and electric stimulation, both vaginal electric stimulation for vaginismus and the more controversial sacral neuro-modulation implant with its dearth of data. The authors of this comprehensive review article state that while classification systems and therapeutic options continue to evolve, much is lacking with regard to understanding, defining, evaluating and treating female sexual dysfunction.  This is a meaningful review for all clinicians, be they specialists in treating female sexual disorders or general primary care clinicians interested in knowing more about a subject affecting more than ½ of their patient population.

(c) 2010 Lauri Romanzi

Stone age sex toy, built to last

Our dear friends at Betty Dodson central command (www.dodsonandross.com) continue to delight, the latest being their posting on an awesome (truly) anthropologic find – a stone-age dildo replete with carved rib rings and obligatory mushroom cap, lest future generations doubt its purpose.

stone age sex toy found in German cave

And now Dodson and Ross bring us more news – yet another pre-historic sex toy un-earthed intact, pret a porter….

Stone-aged sex toy #2 - the more things change, the more they remain the same...

Durability counts.

Dr. R’s blogpost  A word from the wise on Prolene mesh and your prolapse surgery is featured in the esteemed Grand Rounds Medical Blogsite hosted this week at   FDAzilla by Tony Chen. Included with a dozen or so other blogposts on the complications of interacting with the FDA, we highly recommend a perusal of the participating blogs on topics such as The Great Autism Vaccine Fraud by the “ancient but awesome” Joel Shurkin, Dr. Pullen’s top 6 rules of wicked good medicine, and a A Swedish man forced to amputate his cancer-ridden penis after waiting a year for treatment, to name a few. Enjoy!

January 2, 2011

This past fall, courtesy of beloved colleague Patricia Allen, MD and Womens Voices for Change,  I attended an early premiere of the film “Desert Flower” at the Museum of Modern Art in New York. The English-speaking version is scheduled for U.S. release in February, 2011. A movie based on the true story of Waris Dirie, Somali-born super-model who first revealed the truth about her own circumcision to Barbara Walters (20/20: A HEALING JOURNEY WARIS DIRIE: 07/10/1998), Ms Dirie was subsequently appointed UN Special Ambassador, speaking out against female genital mutilation through the United Nations, World Health Organization, and her own Desert Flower Foundation.

The film chronicles her journey from nomadic childhood to international fame, all underscored by the impact of her ritual circumcision, performed on top of a rock in the desert when she was just a toddler.  Already released in Germany, I highly recommend making time to see this film when it’s released next month in the States.

Women's International Network, founded 1975

I first learned of female genital mutilation (FGM) in the ‘80’s, through the groundbreaking work of Fran P. Hosken, editor of Womens International Network News and author of The Hosken Report: Genital and Sexual Mutilation of Females (first edition 1979). Ms. Hosken presented her work at the First International Symposium on Circumcision in Anaheim California in 1989, explaining that conservative estimates put “84 million women and girls”  undergoing or suffering the results of genital circumcision, mostly in continental Africa, also along the Persian Gulf, Indonesia and Malaysia. More common in Moslem communities, the practice is always tied to rites of passage – a woman cannot marry or become a full member of the community without undergoing whichever version of FGM her community practices. As families from these cultures immigrated to Europe and North America, many sought and still seek to maintain FGM in their American and European-born daughters, with reports of black-market FGM done by doctors and other licensed health clinicians, or carried out ritualistically by other émigrés or family members, often with fatal results.

Fran Hosken paper 1989, 1st International Symposium on Circumcision

Called Infundibulation, Infibulation, Female Circumcision, Female Genital Cutting, or Female Genital Mutilation, it is, by any name, horrific in intent and in fact. Designed to secure virginity by making sexual intercourse impossible, the clitoris may also be removed in the process to provide the additional “benefit” of eliminating and controlling female sexual desire. The degree of excision is dictated by cultural practice, so that women in any given community with all undergo the same sort of genital cutting.

The severity of the excision varies, categorized into 4 methods:

Type I: removal of clitoral hood, tip of clitoral glans, small potion of labial minora

Type II: removal of entire clitoris, part or all of labia minora

Type III: “Pharaonic” – the most extreme – complete removal of clitoris, complete labia minora and most of labia majora, leaving a tiny opening for passage of urine and menstrual blood.

This extreme excision was recorded in Ancient Egypt over 2000 years ago, hence the Pharaonic label.

Type IV vaginal scarring, piercing or nicking that causes the vagina to close

This tie to cultural rites of passage has sparked debates in various political and anthropologic circles regarding the potential for cultural bigotry, concerned that Euro-American standards ought not be applied to these ancient genital practices, pointing out that circumcision of males, normal and for a time almost ubiquitous in the States, illustrated the need to “respect” these practices on females. Women and girls seeking international asylum to avoid such procedures were turned away or held in detention as debates raged (EU Agenda on FGM).

As of 1999, the Fact Sheet on U.S. Intervention on Gender Equality, Equity and Empowerment of Women released by the U.S. Bureau of Populations, Refugees and Migration 1999 contains among its six stated goals; “combat violence against women, eliminate female genital mutilation, and reduce sex trafficking”. How sex trafficking got mixed up with the cloistering impact of FGM, and why sex trafficking is not also in the cross-hairs for elimination (reduction deemed sufficient) is a topic for another day.  A federal acknowledgement of FGM as a wrongful act was a hard won step in the right direction, no matter its bedfellows.

The gripping ritualistic mandate and physical horror are captured equally in these excerpts on infundibulation practices in Somalia and Nigeria from the 4^th edition of The Hosken Report:

Middle-East-Info.org: Hosken Report excerpt 1993

SOMALIA CASE REPORT: In Somalia, infibulation is practiced by the entire population –indeed by all ethnic Somalis wherever they live. This practice has existed for as long as anyone can remember and is recorded in the earliest historical accounts (see “History”). Though it is traditionally called “circumcision “, the extreme form of the mutilations to which little girls are subjected is not accompanied by any rituals, festivities, or celebrations such as is done traditionally in Sudan or other African countries designed to disguise the harshness and brutality of the violence.

Here below is an eyewitness account of what is done to all Somali girls because men still today refuse marriage with an uninfibulated, or what is called “open”, bride. And without marriage there is no future for a girl:

“With the Somalis, the circumcision of girls takes place in the home among women relatives and neighbors. The grandmother or an older woman officiates. At each occasion, usually only one little girl or at times two sisters are infibulated; but all girls, without exception, must undergo this mutilation as it is a required for marriage.

The operation itself is not accompanied by any ceremony or ritual. The child, completely naked, is made to sit on a low stool. Several women take hold of her and open her legs wide. After separating her outer and inner lips, the operator, usually a woman experienced in this procedure, sits down facing the child. With her kitchen knife the operator first pierces and slices open the hood of the clitoris. Then she begins to cut it out. While another woman wipes off the blood with a rag, the operator digs with her sharp fingernail a hole the length of the clitoris to detach and pull out the organ. The little girl, held down by the women helpers, screams in extreme pain; but no one pays the slightest attention.

The operator finishes this job by entirely pulling out the clitoris, cutting it to the bone with her knife. Her helpers again wipe off the spurting blood with a rag. The operator then removes the remaining flesh, digging with her finger to remove any remnant of the clitoris among the flowing blood. The neighbor women are then invited to plunge their fingers into the bloody hole to verify that every piece of the clitoris is removed.This operation is not always well-managed, as the little girl struggles.

It often happens that by clumsy use of the knife or a poorly-executed cut the urethra is pierced or the rectum is cut open. If the little girl faints, the women blow pili-pili (spice powder) into her nostrils. But this is not the end. The most important part of the operation begins only now. After a short moment, the woman takes the knife again and cuts off the inner lips (labia minora) of the victim. The helpers again wipe the blood with their rags. Then the operator, with a swift motion of her knife, begins to scrape the skin from the inside of the large lips.

The operator conscientiously scrapes the flesh of the screaming child without the slightest concern for the extreme pain she inflicts. When the wound is large enough, she adds some lengthwise cuts and several more incisions. The neighbor women carefully watch her ‘work’ and encourage her.

The child now howls even more. Sometimes in a spasm, children bite off their tongues. The women carefully watch to prevent such an accident. When her tongue flops out, they throw spice powder on it, which provokes an instant pulling back.  With the abrasion of the skin completed according to the rules, the operator closes the bleeding large lips and fixes them one against the other with long acacia thorns.

At this stage of the operation the child is so exhausted that she stops crying but often has convulsions. The women then force down her throat a concoction of plants. The operator’s chief concern is to leave an opening no larger than a kernel of corn or just big enough to allow urine, and later the menstrual flow, to pass. The family honor depends on making the opening as small as possible because with the Somalis, the smaller the artificial passage is, the greater the value of the girl and the higher the bride-price.

When the operation is finished, the woman pours water over the genital area of the girl and wipes her with a rag. Then the child, who was held down all this time, is made to stand up. The women then immobilize her thighs by tying them together with ropes of goat skin.

This bandage is applied from the knees to the waist of the girl and is left in place for about two weeks. The girl must remain lying on a mat or the entire time while all the excrement evidently remains with her in the bandage.After that time, the girl is released and the bandage is cleaned. Her vagina is now closed – except for a tiny opening created by insertion of a straw or reed and remains closed until her marriage.

Contrary to what one would assume, not many girls die from this torture. There are, of course, various complications which frequently leave the girl crippled and disabled for the rest of her life.”

NIGERIA CASE REPORT: A survey by the federal Ministry of Health gives an overview of the current status ofFemale Circumcision in Nigeria as FGM is locally called. This official document of March 1981 is signed by Dr. O. A. (Mrs.)Adelaja, Senior Consultant/Medical Statistics and gives an overview of the situation:

“According to the response obtained from questionnaires completed by most Nigerian states, female circumcision is still being practiced in most states of this country. It is practiced mostly on babies and small girls of Christian and Muslim parents. But certain tribes perform the ceremony when the female is ready to wed or when the first pregnancy is about seven months. Very few tribes perform the ceremony after marriage and in such tribes, it is the duty of the husband to perform the operation.”

Next, the circumstances of the operations are described:

“The ceremony is usually performed on a group of girls, though some report that individual girls are circumcised in their respective homes. A token fee is paid and ranges from two naira to ten naira. The operator may be a man or a woman. Male operators usually perform it as a business and circumcise male children as well. Tools in use vary and include a small knife, a sharp blade, or a razor.

Post operative management also varies, some report hot fermentation with charcoal daily and feeding with roasted meat and some gruel. Snail juice and palm oil are poured on the incision by some. Native soap and native medicine are also used by another tribe.

Complications: Some deny any complications. But among those who admit complications, bleeding is the commonest problem reported. Other complications include tear, septicaemia, fistula, stenosis, delayed second stage labor, tetanus, urinary obstruction, and dyspareunia.

Reason for Circumcision: The majority attribute the operation to age-old custom, culture and tradition. Some claim that circumcision will prevent promiscuity and reduce sex urge, while others believe that if the newborn baby’s head touches the clitoris, such a baby will die.

Death-by-clitoris, or “mythology run amok”, take your pick.

The medical community appears to have caught up with pioneers like Fran Hosken of Women’s International Network and Molly Melching of Tostan, with corroborating research data, including findings just out this month from Kuwait University and King Faisal University in Dammam, Saudi Arabia showing the persistence and devastation wrought by this brutal tradition. (Female Circumcision:…Unabated in the 21st Century) 4800 pregnant Kuwaiti and Saudi women were evaluated for FGM over a four year period. The prevalence Female Genital Cutting was 38%. Circumcised women had longer hospital stays, higher rates of prolonged labor, cesarean delivery, hemorrhagic bleeding, death of the newborn, and hepatitis C. Flashbacks to the cutting event were reported by 80%, 30% met criteria for post-traumatic-stress disorder relating to the cutting event, 58% had major psychiatric disorders, and 38% had chronic anxiety. These researchers conclude that “Female circumcision is associated with adverse materno-fetal outcome and psychiatric sequelae. Many will need psychiatric as well as gynecological care.”

Compulsion to participate in community ritual can be both bizarre and fierce, as illustrated in the 1989 book Our Grandmothers Drums by Mark Hudson. In 1985, the author worked in a Dulaba village in Gambia, West Africa, “where the women are bound by Islam, female circumcision and subservience to their mothers and men”.  In this village, a British-borne aide worker’s teen daughter, who had been born and grew up in the village, was reportedly so enthusiastic to go through the entire ritual of her home-community that her mother was forced to lock her in her room for the entire weeks-long affair to prevent her daughter from voluntarily submitting to FGM, an integral part of the ceremonies.

And therein lies the key – the divorcement of these crucial rite-of-passage rituals from the brutal practice of female genital mutilation. While important, no amount of legislation in the countries where FGM is practiced will eradicate FGM from the remote, poor communities who hold it dear unless the people themselves want it so.
Enter TOSTAN. Tostan is the Wolof word for “breakthrough” and “spreading and sharing”. Founded in Senegal by Molly Melching (U.S. expat) in the 1970’s, Tostan’s track record of success in eradicating FGM cannot be overstated. Working with the communities for literal decades, Tostan’s premier FGM abandonment break-through started with a single Senagalese village in 1997. Since that first group of village women came forward to publicly declare the end of FGM in their community, 4854 more villages in 5 countries (Senegal, Guinea, The Gambia, Burkina Faso and Somalia) went on to eradicate FGM from their rites, rituals, ceremonies and marriagability mandates. This number recently broke through the 5000 mark, as a 3 year Tostan initiative was celebrated by an additional 700 Senegalese villages abandoning FGM on November 28, 2010 :

700 Senegalese Villages abandon FGM

“Aset Mballo, a mother of four from Saré Bidji, declared with her village for the second time. Like many of those present, Aset had participated in Tostan’s Community Empowerment Program (CEP), hailed a “revolutionary approach” by Senegal’s Director of the Family – Ndeye Soukkeyna Gueye – in her speech at the declaration.

The three-year-long Tostan program is taught in local languages and offers human rights-based education focused on democracy, problem-solving, health, literacy and management skills. “I’m here today to teach children and parents about the health problems that are caused by female genital cutting and child marriage. My daughters will not be cut, and I want to bring an end to these practices everywhere!” said Aset.”

Thank you Fran Hosken, Thank You Molly Melching, Thank You Waris Dirie.

What better time for the English-version debut of “Desert Flower” than now?

(c) L. Romanzi 2011

Recently returned from Senegal, I came across a webposting from a USAID sponsored project to improve contraceptive access for women in this epic land of the Wolof, Fulani, Mandigo, Toucouleur and Diola.

Read for yourself here:

IntraHealh International Contraception Program in Senegal

The piece ends with

This work is an important step toward decreasing unmet need for family planning in a country where it is estimated that only 10% of married women use contraception.

…implying that lack of access is the biggest problem. And maybe it is. But in my experience, the backstory on contraception in settings of dire poverty direct from the mouths of the women it hopes to serve goes something like this:

My commentary to the blogpost:

Creating supply only works when there is demand. Dire poverty does not create demand for birth control, it decreases it, in part because poverty leads to high death rates for newborns and infants. Women living in a community where babies die young don’t want to do anything to impair the ability to conceive more children. According to Populations Reference Bureau, the 2008 infant mortality in Senegal was 58/1000 live births, equivalent to Tanzania, and far below the highest, in Afghanistan, at 155/1000 live births ( www.prb.org). I do hope that this intermediate infant mortality ranking reflects ongoing programs to reduce maternal and neonatal mortality, without which a rejection of this national contraceptive outreach program by the women it hopes to serve is virtually certain. That said, well done!  When it comes to family planning, nothing is possible without access to short and long term contraceptive methods.

This program is lead by Intrahealth and funded by US Agency for International Development as part of the parent program: Maternal, Neonatal, Child Health, Family Planning and Malaria Project. For perspective, Malaria is arguably the leading cause of death on the African continent : World Life Expectancy.

(c) Lauri Romanzi 2010

Uterine Prolapse – The Facts

Uterine prolapse affects 30% of ALL women, so there’s a good chance that it will touch you or someone you know. But before you can comprehend uterine prolapse, you need to have a basic understanding of a woman’s pelvis.

The vagina is the foundation of female anatomy, while the cervix sits above the vagina, and the uterus above the cervix. Connective tissue called uterosacral ligaments hold the uterus and cervix in place.

When it comes to uterine support, it's all about the uterosacral ligaments...

As the primary support system for the entire female pelvis, the uterosacral ligaments are extremely important! Uterine prolapse occurs when collagen fibers in these ligaments stretch or weaken, causing the cervix and uterus to drop down to the vaginal canal. If it drops far enough, it’s possible to feel and see the cervix, which looks like a small pink donut.

Although this is not usually painful, a woman may experience feelings of heaviness or pulling in the pelvis. Other symptoms of uterine prolapse may include painful sex, low backache, frequent urination, or even vaginal bleeding, although the converse is not always true, i.e; every women with frequent urination or low back pain or vaginal bleeding does not necessarily suffer uterine prolapse, as there are many reasons, prolapse among them, for each of these conditions. Your gynecologist can help sort out whether or not you are suffering uterine prolapse.

Like I said, it's all about the ligaments

A number of things can contribute to uterine prolapse. Women who give birth vaginally are more likely to experience thinning and stretching of the supportive uterosacral ligaments,especially those who experience long labors or deliver big babies. Prolapse is also more likely in women over 50, because muscle tone and onnective tissue integrity decreases with age.

Research also suggests that some women may be genetically predisposed to uterine prolapse. In other words, you can’t always PREVENT uterine prolapse, but you CAN learn about treatment options.

One effective treatment choice is a pessary, which is a vaginal support made of rubber, plastic, or silicone. A doctor fits a woman’s pessary to her body to hold the prolapse comfortably in place.

Surgery is another option, which, unlike a pessary, actually REPAIRS the prolapse. As with all surgeries, complications, including but not limited to recurrence of prolapse, are possible so make sure you understand both the risks and the benefits if you are considering prolapse surgery.

According to US Dept of Health data, one in nine cases of uterine prolapse is severe enough to warrant surgery. The good news is that uterine prolapse IS fixable without resorting to hysterectomy, so if you’re suffering uterine prolapse, understand that you don’t have to choose between hysterectomy or pessary, you have the option of uterine resuspension, hysterectomy-type prolapse repair, or pessary support.

To learn more about this and other pelvic floor conditions, visit Dr R video on HealthGuru.com.