SEXUAL DYSFUNCTION AND THERAPY

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Dear Patient in Pain,
You mention that the pain is always in the same spot, but even if you feel it there, the trigger point might be someplace else. We recommend you find a physician with experience in diagnosing and treating different types of pain. Make sure your physician is able to replicate the pain in the office and can identify the pain trigger point. In our office, we work with a variety of treatments for pain including some combination of different stretching exercises, medication and biofeedback. While pain can be difficult, it is treatable and you don't need to suffer.

Good luck,
Bat Sheva Marcus, LMSW, MPH, PhD
Clinical Director

Dear DC,
While it is impossible to diagnose or treat you over the Internet, what you are describing sounds very common.

In addition to scar tissue, your pain may be increased due to hormonal issues. We would recommend a hormonal evaluation in conjunction with a program of exercises to stretch the tissue. A specialist who is willing to consider multiple factors and develop a customized treatment combination will be best suited to address your specific concerns.

Good luck,
Bat Sheva Marcus, LMSW, MPH, PhD

Thank you for your letter. What you are describing is not unusual at all. While it is impossible to diagnose you without a physical exam, it could be one of a few things. It could be a yeast infection, vaginismus, dysparunia, or many other potential issues.

You need to find a medical practice, such as The Medical Center for Female Sexuality, that specializes in diagnosing and treating pain disorders. Since pain in different parts of the vagina is treated differently, a specialist will be able to identify and treat the problem. Click here to visit our Web page about pain.

Good luck,
Bat Sheva Marcus, LMSW, MPH, PhD

It is not at all uncommon to experience pain with intercourse. It often happens as women age and/or if there has been a prolonged period without intercourse.

Although estrogen and lubrication can help, more often than not, the area has to be “re-stretched,” which is truly not a complicated process. It just takes a bit of determination, commitment, and know-how.

You didn't say where you live, but you can call and make an appointment to see us at our Westchester or Manhattan office.

We've had a great deal of success in this area, so please don't give up hope.

Best of luck to you,
Bat Sheva Marcus LMSW, MPH, PhD
Clinical Director

Obviously, we can't diagnose you over the Internet. However, the problem could be due to low estrogen, lack of lubrication, or unexplained atrophy. What we would probably do is work with you, incorporating topical anesthetics and dilators to try and re-stretch the area and explore better lubrication options with you. You can discuss these issues with your gynecologist or you can make an appointment to see us.

I also suggest that you and your boyfriend explore non-intercourse sex as well during this time. There are many ways to have a great sex-life without intercourse.

Don't give up hope. We've helped other women with similar unexplained pain issues.

Bat Sheva Marcus LMSW, MPH
Clinical Director

Obviously we can't diagnose you over the Internet, but what you are describing is not particularly uncommon. It often happens to women after they have had a hysterectomy. It may be a symptom of a physical changes, hormonal issues, or medications. We've had very good results using a combination of treatments in these situations.

The pain could be due to low estrogen, lack of lubrication, or unexplained atrophy. This is also common with a hysterectomy. What we would probably do with you is work with topical anesthetics and dilators to try and re-stretch the area and explore better lubrication options with you. The best you can do is to set up a consultation with a specialist. If you are not within driving distance from Westchester County , NY , we have recently introduced enhanced treatment programs for patients who would need to travel to see us. Click here to learn more. You should get a complete physical and psychological work-up to see if the causes of the problem can be identified and then treated.

Please don't give up hope. We've helped many other women with low desire and similar unexplained pain issues.

Bat Sheva Marcus LMSW, MPH
Clinical Director

Pain can be very challenging to treat, but do not give up hope. I am unable to diagnose you over the Internet, but your gynecologist may be able to help. When confronted with a patient who is suffering pain, we typically try to recreate the pain in the office. This helps us to develop a treatment plan.

Frequently, pain can be caused by a loss of elasticity. We normally treat a loss of elasticity using a combination of topical lidocaine and graduated dilators. If your gynecologist is unable to develop a treatment plan, give us a call and we will determine the cause of the pain and how to treat it.

Good luck!

Bat Sheva Marcus LMSW, MPH
Clinical Director

Okay. Our first suspicion in a situation like yours would be hormonal.

Generally speaking, we do a first 1 1/2-hour meeting for diagnosis (An hour with me on a psychosexual history and a half hour with the nurse practitioner on a physical exam, blood tests, etc.). Then we see the patient two weeks later for a follow up once we've reviewed all blood test results, other tests, notes, etc.

What we've done in a situation like yours where someone is coming from out of town is schedule a Monday evening meeting and a follow up on that Wednesday morning. We expedite the most important tests and our meetings.

If you are then put on a regimen of hormones, we generally want blood tests run in our office every ten weeks or so but we can sometimes make arrangements to work with a lab that is local to the patients. We could have some follow up done by telephone but at least three follow-up appointments during the first year would have to be in person. Later, we could taper down.

The bottom line is if you are willing to come to New York once for a Monday evening and Wednesday morning visit and then three other times during the year, it is certainly doable.

Send your address and I will have the front desk mail you out information and paperwork. Then you can decide if this is something you want to pursue.

Best of luck to you.
Bat Sheva Marcus LMSW, MPH
Clinical Director

Testosterone therapy is usually provided in the form of a cream that enters the blood stream and affects the whole body. Sometimes it is given in a pill format of a hormone that is a predecessor of testosterone.

You should not attempt to increase your testosterone levels without medical supervision. It is important to monitor levels and make sure that they are not too high (or too low). Also, like any other hormone, testosterone has side effects and it is important to have them monitored.

Be aware that it is not an "overnight solution" and can take a number of months as well as refining of the dosages to get you to the place you want to be. Make sure that the practitioner you are seeing has a good understanding of effective blood levels (which may not be the same as "normal" blood levels in this instance) and monitors all of your blood levels closely for safety purposes.

You did not say what symptoms you were having so it is difficult to respond to a specific issue. However, women with low testosterone as well as a number of other hormones often experience a sudden and dramatic drop in level of desire.

Please don't get discouraged. There is every reason to believe that with the right treatment you will see tremendous improvement!

Bat Sheva Marcus, LMSW, MPH, PhD
Clinical Director

What you are describing is not particularly uncommon and can happen to women at any age. It may very well have nothing to do with you or the relationship and can be a symptom of a physical or hormonal issue, or it may be reflective of problems in the relationship. The best you can do is urge your girl friend to set up a consultation with a specialist. She should get a complete physical and psychological work-up to see if the causes of the problem can be identified and how to provide a solution for both of you.

We've helped many women in this situation so don't give up hope.

Good luck to you.

Bat Sheva Marcus LMSW, MPH
Clinical Director

What you are describing is not uncommon and like you, often women find it very confusing to be able to enjoy sex, easily reach a climax and yet avoid sex and find that they still have little to no desire. Often, it is even more difficult for a partner to understand this since they feel: "well, she had such a good time the last time we had sex, what's stopping her now?" The reality though, is that much as they are intertwined with each other, desire and arousal can be separate, and often are. What you are describing is a fairly pure lack of sexual desire. In trying to address the problem, the obvious reasons should be examined first. Do you have time to be sexual? Are you so overwhelmed by household chores, work or children that you aren't really leaving any time for sex? Does your partner know how to approach you in a way that is appealing to you? However, in addition to looking at these factors, you should be screened for depression and also have your thyroid tested as well as your general hormone levels. Often, when the level of testosterone or other hormones get extremely low, women find themselves in the situation you are describing. For reasons we don't fully understand yet, low hormones seem to translate in our brain to "I don't really feel like having sex" or to "I really, really don't feel like having sex." Visiting a center like The Medical Center for Female Sexuality will allow you to be evaluated to determine what is causing your low desire so you can find a solution.

Best of luck to you.

Bat Sheva Marcus LMSW, MPH
Clinical Director
The Medical Center for Female Sexuality

When you say you need to have sex, is it that you feel physically aroused (like your clitoris is engorged) and you need one or more orgasms to relieve the physical sensation or is it a combination emotional/physical need to be sexual, where you are fantasizing about sexual encounters, etc.

The former is Persistent Sexual Arousal Syndrome (PSAS), which is not really sexual in nature but more nerve-related. There is not a great deal of research on it but there are some treatments that can be used. The second sounds more like a possible hormone imbalance, perhaps mixed with psychological issues as well.

You should definitely speak with your doctor about your concerns. If your doctor seems uncomfortable, there are specialists who can help you. If you are able to come to The Medical Center for Female Sexuality, we have a number of treatments to explore. If not, try to find a similar medical center in your area.

Bat Sheva Marcus LMSW, MPH
Clinical Director

Yes. What you are describing, a sudden and dramatic drop in the level of female sex drive is not uncommon. In our experience, it is often directly linked to testosterone levels as well as a number of other hormones.

We have helped many women in your situation by prescribing hormone replacement or supplementation. Obviously, without seeing you and without doing a full panel of blood tests, it is impossible to diagnose and treat you. Be aware that hormone replacement is not an “overnight solution” and can take a number of months as well as refining of the dosages to get you to the place you want to be. Make sure that the practitioner you see has a good understanding of effective blood levels (which may not be the same as “normal” blood levels in this instance) and monitors all of your blood levels closely for safety purposes.

Please don’t get discouraged. There is every reason to believe that with the right treatment you will see tremendous improvement!

Bat Sheva Marcus, LMSW MPH
Clinical Director.

Obviously, it is impossible to give you medical advice over the Internet. There may be physical causes in which case you might need a physician. A suggestion that works for some women is adding erotica into your sexual mix. You could read it before your husband joins in, he could read it to you, or you could read it to him. Mix it up a little and have some fun with it. Another suggestion is to try reading it alone while you are masturbating. Without the pressure to perform for another, this is a great opportunity to explore your sexuality.

Best of luck to you,
Bat Sheva Marcus LMSW, MPH, PhD
Clinical Director

It is impossible to diagnose you over the Internet without an examination and certain tests, but what you are describing sounds like HSAD (hypoactive sexual arousal disorder) and anorgasmia. This can be due to low hormone levels, problems with blood flow, neurological issues and even sometimes, psychological issues. The only way to address the problem is to have a complete exam. I don't know how far away you are from our center, but I will have a package mailed out to you. If you are too far away, we have recently introduced a distance treatment program that will condense your treatment into a shorter period. We begin with a phone consultation so if you are interested in pursuing this, give us a call at (914) 683-0000.

Do not give up hope. We have seen many women in your situation improve dramatically.

Best of luck.

Bat Sheva Marcus LMSW, MPH
Clinical Director

It is obviously impossible to diagnose you over the Internet. What you are describing however sounds like HSAD (hypoactive sexual arousal disorder) and anorgasmia. This can be due to low hormone levels, problems with blood flow, neurological issues and even sometimes, psychological issues. The only way to address the problem is to have a complete exam. I don't know how far away you are from our center, but I will have a package mailed out to you. If you are too far away to come in here, the package should provide you with some background to discuss the issue with your ob/gyn. Perhaps your doctor can recommend some more testing and treatments.

Do not give up hope. We have seen many women in your situation improve dramatically.

Best of luck.

Bat Sheva Marcus LMSW, MPH
Clinical Director

Dear Writer,

You are asking whether you "should" get pleasure from intercourse and whether it is normal not to. There is a huge variation among women regarding pleasure from intercourse and this can even vary at different points in a woman’s life. Some women love the feeling of vaginal penetration. Either because they have many nerve endings in the vaginal canal or perhaps they love the closeness that intercourse provides. Some women could take it or leave it and find they get much more pleasure from breast touching, vulvar stroking and clitoral stimulation. Neither is more normal or more correct. It is just a matter of working out a sex life that works for you and your partner. If you prefer when he touches you with his hands or his mouth, make sure that is a big part of your sex life. If he wants to have intercourse, you can still do that. Perhaps have him touch your clitoris while he is inside you or touch your clitoris yourself. Some women find they have stronger orgasms when they touch themselves when they have a penis inside them. The best thing to do is both accept it and use it as a springboard to expand and develop a fun and varied sex life that turns you on and gives you orgasms. Also, be aware that the situation might change and 5 or 10 years from now you might find yourself loving intercourse. We change as sexual beings from day to day and year to year. Our hormones change and our nerve-ending responses shift. Pay attention and your sex life will vary accordingly.

Best of luck to you,

Bat Sheva Marcus, LMSW, MPH, PhD
Clinical Director

Dear P,

Obviously, it is impossible to provide a diagnosis or medical advice over the Internet, but before you consider medical intervention, I have a suggestion that has worked for some women in your situation. You didn’t mention what type of vibrator you used, but try a strong, plug-in vibrator (such as the Hitachi Magic Wand). At the start, you may have to use it for long period of time (even 45 minutes) for a few days in a row.

Good luck,

Bat Sheva Marcus, LMSW, MPH, PhD
Clinical Director

You are not crazy and you are not imagining things. The class of anti-depressants called SSRIs (selective serotonin reuptake inhibitors) works extremely well as anti-depressants or anti-anxiety medication. However, for many individuals (some studies find as high as 70%), they have an immediate and dramatic impact on desire, arousal, and the ability to orgasm. The best thing to do is to discuss the issue with whoever prescribed the Paxil and see if they can either try you on a different SSRI to see if you have fewer side effects or to see if you can try a different class of anti-depressants.

Good luck,

Bat Sheva Marcus, LMSW, MPH, PhD
Clinical Director

It is not clear from your e-mail if you meant that you are unable to have an orgasm while you are having intercourse even if you are using other stimulation (hand or vibrator), while you are having intercourse. If you meant that you cannot have an orgasm from intercourse alone, please realize that only 30% of women experience orgasm from intercourse alone. That is, MOST women do not get enough stimulation to their clitoris from the penis inside the vagina to have an orgasm and there is absolutely nothing wrong with you if you can’t have an orgasm from intercourse. It is not a dysfunction.

All orgasms are produced by stimulation to the clitoris. Some women are built in such a way that their clitoris is closer to the vagina so that stimulus in the vagina from the penis actually rubs the clitoris to the point where they have an orgasm. But most women’s bodies are not built that way. It is just another physical characteristic, like some women are shorter or taller than others. Most women have an orgasm using a hand, a mouth or vibrator. They can used their own hand or their partner can use his hand or they can use a vibrator while they are having intercourse if it is important to them to have the orgasm while their partner’s penis is inside of them. Others choose to have an orgasm either before or after intercourse.

I hope this is helpful. If you feel the need for a full evaluation, you can make an appointment with the center.

All the best to you,

Bat Sheva Marcus LMSW, MPH
Clinical Director

You probably would know if you have had an orgasm. It is an involuntary response that takes over your body for a few seconds.

The first thing I would recommend is that you purchase a book called The Guide to Getting It On by Paul Jahannides. It will give you more information. Actually it will probably give you all the information you may ever need on sex. Another very useful book you should purchase is Sex For One by Betty Dodson. You may want to visit her Web site as well. She has a number of videos that show her teaching women to have orgasms. They are very professional and tastefully done.

The second thing I would recommend is that you consider using a vibrator. A vibrator is able to provide high levels of stimulation for a prolonged period of time in a way a partner may not be able to with his hand or mouth. Your partner can use the vibrator on you, either with or without and during, before or after intercourse. Alternatively, you can use the vibrator on yourself.

You did not say where you lived, but if you are near Westchester NY , you may want to consider coming in for a full evaluation. We have a variety of techniques we use to help patients who have trouble with orgasms.

In the meantime, good luck and don't get discouraged. With patience and practice you will be able to achieve an orgasm.

Bat Sheva Marcus LMSW, MPH
Clinical Director

Vaginal fluids are a complicated issue to discuss without a physical exam because they differ dramatically between women. Some vaginal fluids are normal, healthy and necessary and still one woman can experience being significantly “wetter” than another with these same fluids. Sometimes fluids can be a sign of infection or irritation and these can be uncomfortable, itch, or burn. Finally, some women find that they “ejaculate” when they have an orgasm and this, too, varies greatly from woman to woman. I would suggest that you make an appointment to discuss this with an ob/gyn or specialist in your area. You need an exam to figure out exactly what is causing this, if it requires treatment and what the treatment would be.

Best of luck to you,

Bat Sheva Marcus LMSW, MPH, PhD
Clinical Director

While we can't diagnose you over the Internet without laboratory tests, this sounds like bacterial vaginosis (B.V.). Certain women seem to have a propensity for B.V. We would probably begin by treating you with an extended regimen of Metrogel. In addition, we would definitely explore dietary issues since they can cause B.V. While we do not have extensive experience with .BV., we have worked with similar conditions such as chronic yeast infections and vulvar vestibulitus. Please be aware that conditions like these involve a great deal of trial and error. On this issue, as well as on other issues, we continue working with a woman until she feels that she has relief from the problem, but often it takes time.

Best of luck to you.

Bat Sheva Marcus LMSW, MPH
Clinical Director

It is impossible to diagnose you over the Internet, but we do have some suggestions. If you are unsure what caused the pain, it might make sense to try again, to see if you experience the pain again. Sexual penetration may cause pain the first time, due to the tearing of the hymen, a small piece of tissue across the vaginal opening. When you try again, if you do not experience the pain, you know that it was caused by the tearing of the hymen. If you do feel the pain again, you should consult your gynecologist. He or she will be able to perform an exam and determine some of the possible causes of your pain. As far as receiving pleasure from the activity, what you enjoy and how will change as you age or even with different partners. Not all women experience an orgasm from vaginal penetration, so that should not be a concern. It might change when you experience penetration with a partner or as you age.

Role-playing can be done in a variety of ways. It basically means pretending to be something different from what you are. It can incorporate costumes and props, but it doesn’t have to. It can incorporate an elaborate story line, but it doesn’t have to.

Many couples explore role-playing, especially those who are in established relationships. Along with adding some excitement, role-playing allows you to explore different aspects of your sexual personality. This may be a great chance to find something new that you both enjoy.

Remember to pick a scenario that is comfortable to both you and your partner. If you can get involved in the role-playing, it will allow you to have some fun while building additional trust into your relationship and expanding your sexual boundaries.

There is no empirical evidence to suggest that clitoral pierces enhance sensation during orgasm. And that does not seem to be the experience of women who have had it done. What clitoral piercing does accomplish is inserting a stimulant on the clitoris that can be felt regularly throughout the day. Essentially, women are having their clitoris stimulated during the course of their day-to-day activity and may therefore be aroused.

It is not without risks although I don't have additional information on the procedure as we don't do it in our office.

Best of luck to you.

Bat Sheva Marcus LMSW, MPH

While many patients come to our Purchase, NY location from New York City (and even from Pennsylvania and Delaware), we recently opened an office in Manhattan. You can reach our Manhattan office by calling (646) 839-0700. The Manhattan office is located two blocks from Grand Central Station in midtown Manhattan on the East side.W

We have the same capabilities and unique treatment programs available at our Manhattan office as we have in Purchase, you can contact us at either office for more information.

Good luck,

Bat Sheva Marcus, LMSW, MPH, PhD
Clinical Director

We have worked with patients in the past who have made a trip specifically to visit our office. Generally speaking we do a first 11/2-hour meeting for diagnosis, and then we see the patient two weeks later for a follow-up once we've reviewed all bloodwork, tests and notes.

What we've done in a situation like yours where someone is coming and needs to stay in the area is schedule a Monday evening meeting and a follow up for that Wed morning. We expedite the most important tests and our meetings.

If you are then put on a regimen of hormones, we generally want blood tests run in our office every 10 weeks or so but we can make arrangements to work with a lab that is local to you. We could have some follow up done by telephone but at least 3 follow-up appointments during the first year would have to be in person. Later we could taper down.

The bottom line is if you are willing to come to NY once for a Mon- Wed and then 3 other times during the year, it is certainly doable.

Best of luck to you.

Bat Sheva Marcus LMSW, MPH
Clinical Direct