The V Book - For Clinicians

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Medical Sidebars from The V Book
Normal Bacteria in a Healthy Vagina

Organism % of Women Harboring the Bacterium

Lactobacillus 68

Corynebacterium 31

Streptococcus 37

Enterococcus 26

Staphylococcus epidermidis 53

Staphylococcus aureus 8

Escherichia coli 20

Gardnerella vaginalis 25

Clostridium 12

Peptostreptococcus tetradius 26

Bacteroides 52

Fusobacterium 21

Source: S. Faro, Bacterial vaginitis, Clin Obstet & Gynecol 1977:128:777.

Do Women Ejaculate?
Amazingly, no one’s sure. Release of fluid from the urethra at orgasm occurs in a small percentage of women, who experience it as extremely pleasurable. Some suggest that women can learn how to ejaculate. If it occurs, the ejaculate is about a teaspoon of fluid similar to watery skim milk. Some chemical analyses suggest that this fluid is urine, while others show that it’s different from urine.
Above all, release of fluid is a normal function for some women and does not require surgery or medication to make it go away. Some women report that they stopped having orgasms to avoid wetting the bed. No man would say that! This sounds like an example of a cultural obsession with cleanliness overwhelming what is natural and wonderful. Change the sheets! Use an underpad. Find a towel or some disposable underpads. Fluids and moisture are part of nature, part of womanhood. Fluid represents one of our essential essences, from the lubricating mucus of the cervix and the moisture that comes through the vaginal wall during sexual arousal to the bag of waters surrounding our babies. We are often wet. We don’t need to stop it, to get rid of it, or to hide it. Whether a woman ejaculates or not is less important than the fact that sex bring joy and closeness to both partners.
Sources: B. Whipple and B. R. Komisaruk, Beyond the G spot, Med Aspects Human Sexuality 1998:1(3):19; J. Berman and L. Berman, For Women Only: A Revolutionary Guide to Overcoming Sexual Dysfunction and Reclaiming Your Sex Life (New York: Henry Holt and Company, 2001); H. Alzate, Vaginal eroticism: a replication study, Arch Sex Behav 1985:14; D. C. Goldberg, B. Whipple, R. E. Fishkin, et al., The Grafenberg spot and female ejaculation: a review of the initial hypothesis, J Sex Marital Ther 1983:9:27; F. Addiego, E. G. Belzer, J. Comolli, et al., Female ejaculation: a case study, J Sex Res 1981:17:13; M. Zaviacic, S. Dolezalova, I. K. Holoman, et al., Concentrations of fructose in female ejaculate and urine: a comparative biochemical study, J Sex Res 1988:24:319; E. G. Belzer, B. Whipple, W. Moger, On female ejaculation, J Sex Res 1984:20:403.

Contraception and V Considerations
Your choice of birth control can affect your V health, sometimes depending on your individual situation. If one form is causing V problems, you may want to discuss other options with your clinician.

Contraceptive Possible V Effect

Breast-feeding Low estrogen causes dryness, painful intercourse

Condom Possible latex allergy

Diaphragm Possible latex allergy;
spermicidal jelly may irritate;
increases risk of UTI

Foam, jelly, cream, suppositories May act as irritants

IUD (intrauterine device) Promotes yeast infections;
increased menstrual flow
may lead to irritation from pads

Birth control pill May affect sexual desire;
may increase dryness;
may increase risk of yeast infection

Depo-Provera Low estrogen may cause dryness, painful intercourse

Guilty or Not Guilty

The Charge Key Points to Remember

Tampons are associated with toxic shock. The entire mechanism of TSS is still not understood. Tampons do not cause TSS; staph-produced toxin does. Women can now compare tampon absorbencies, choosing the lowest level compatible with individual needs.

Rayon or rayon/cotton tampons may promote the production of TSS poison. A number of studies show that all-cotton tampons may promote poison production; the debate continues.

Tampons introduce bacteria into the vagina. Tampon use does not significantly alter the population of bacteria or yeast in the vagina.

Tampons promote yeast infections. There is a moderate association of deodorant tampons wih yeast in one study. Tampon use is not generally associated with yeast.

Tampons contain traces of dioxin. A chlorine-free bleaching process has eliminated dioxin from tampons.

Tampons cause vaginal ulceration. Proper choice of absorbency and appropriate use prevent this problem.

Tampons may be associated with endomitriosis. Limited information is available. Only one study suggests an association after use for more than fourteen years in women under 30.

Tampons may alter the size of the hymen. No criteria exist for whether a woman is a virgin or not. No baseline measurement of a girl’s hymen is made, and there is wide normal variation. A tampon could enlarge the opening of a girl with a small hymen, or a tampon inserted at a bad angle could change the hymen. No clinician can say for sure if “virginity is intact.” Tampons are recommended by clinicians to prepare for sexual activity and to facilitate pelvic exam.

For Immediate Relief
While you’re waiting to have a diagnosis confirmed, the following natural and over-the-counter remedies can help you deal with itching and burning.

Sit in comfortably warm water in the tub or a plastic sitz bath container that fits under your toilet seat (available at the drugstore).
Go without underwear as much as possible; when not, wear the loosest clothes you have.
Use ice. Put crushed ice, frozen peas, or frozen corn in a small plastic zip-closure bag with a soft cloth around it. This molds well to V anatomy. At night keep by the bed a plastic dishwashing detergent bottle that you have cleaned, filled with water, and frozen; if you awaken with itching, put this (wrapped in a thin soft cloth) between your legs.
Apply the over-the-counter preparation Vagisil.
Take Benadryl or Dramamine at bedtime to help control the itching, so you can get some sleep.
Ask for a prescription for a topical anesthetic, Xylocaine 5 percent ointment (gel or cream may burn).
One thing not to do: Don’t buy an over-the-counter antifungal (common trade names: Monistat, Femstat, Gyne-Lotrimin) until you have read this chapter through and decided whether you should first see your clinician. I’ll explain later why these creams should not be your very first line of defense.

Steroid Safety
Safe and intelligent use of steroids requires working carefully with your clinician and knowing a few basics:

Carefully follow directions for use.
Ask your clinician for a trusted brand name. There can be big differences in effectiveness between generic and name brand steroids.
Make sure you know exactly where (labia, clitoris, vestibule, perineum, anus) to apply the cortisone. Strong steroids should not be used on the face without careful consultation with a dermatologist. So if you have a bump on the face, don’t put your vulvar steroid on it without asking.
Apply in a thin coating, ideally to hydrated skin for best absorption. A 30 g tube should last several months, depending on the area to be covered.
Never abruptly discontinue steroid use. If the medication is stopped cold turkey, symptoms can bounce back immediately. Work with your clinician to develop a plan to taper off use gradually.
Report side effects to your clinician. If itching develops after you’ve been doing well, the problem may be yeast. A thinning of the skin and bruising—a common side effect of cortisone use generally—are almost never seen when a topical steroid is used only for two to ten weeks, the usual duration for initial treatment.

Detecting HS Early
Early diagnosis of HS is essential, since most cases can be effectively treated when caught early, sparing you a great deal of pain. Signs that suggest early HS include:

Recurrent deep boils for more than six months in places where the skin flexes and is rich in sweat glands
Onset after puberty
Poor response to conventional antibiotics
Strong tendency toward relapse and recurrence
Zits in sweat-gland-bearing skin
No bacteria that cause disease grown from routine cultures of pus from boils
Personal or family history of acne or pilonidal sinuses
Worsening of boils premenstrually in women

One roadblock to early diagnosis is that a patient sees different physicians in different locations and no one puts together a total picture of HS. This is really important! Few processes produce recurrent abscesses and sinus tract formation with a characteristic distribution in the skin that is rich in sweat glands—the armpits, groin, and perineum.
If you are having recurrent boils that leave pits and scars and thickened cords under the skin, find a good general surgeon or a knowledgeable gynecologist or dermatologist and ask about HS.
Source: P. S. Mortimer, Hidradenitis suppurativa—diagnostic criteria, in Acne and Related Disorders, 1st ed., R. Marks, G. Plewig, eds. (London: Martin Dunitz Ltd., 1989), 359.

Ask Yourself
Have you ever said the following? Such statements can help a clinician diagnose VBD.

“I have never been able to use a tampon; it hurts.”
“The doctor needs to use the smallest speculum.”
“Sex is painful; my doctor says I need to relax more.”
“I always have yeast; the creams don’t work.”
“I had a baby months ago but the episiotomy stitches still hurt.”
“I am very small down there, and it’s just too tight.”
“Sex has been painful since menopause, and even with estrogen cream I am not comfortable.”
Source: M. F. Goetsch, Vulvar vestibulitis, Contemporary Ob/Gyn Oct. 1999:56.

What to Rule Out First: Other Reasons for Vulvar Irritation, Pain, or Painful Intercourse
The diagnosis of VBD or VVD is made when all other possible causes of these symptoms—infections, skin diseases, and other medical conditions—are ruled out. The following things can also result in vulvar symptoms or painful sexual intercourse. (Most are explained elsewhere in the book; see Index.)

Infections: Bartholin’s gland abscess, yeast infection, herpes, human papillomavirus, molluscum contagiosum, trich
Trauma: sexual assaults, other physical injuries
Systemic disease: Behcet disease, Crohn’s disease, Sjögren’s syndrome, systemic lupus erythematosus
Precancerous conditions, cancer: vulvar intraepithelial neoplasia (VIN), vulvar cancer
Irritants: soaps, sprays, douches, antiseptics, suppositories, creams, the HPV treatment 5-FU, laser treatment
Skin conditions: allergic or contact dermatitis, eczema, psoriasis, hidradenitis suppurativa, lichen planus (LP), lichen sclerosus (LS), pemphigoid and pemphigus (two rare skin diseases that cause blistering)

Source: H. K. Haefner, M. D. Pearlman, Diagnosing and managing vulvodynia, Contemporary Ob/Gyn, Feb. 1999:110.

Common questions: Vulvodynia and sex
Q How do you find a satisfactory sexual experience despite pain that prevents vaginal intercourse?
A Sexuality implies the totality of a being. It refers to human qualities, not just to the genitals and their functions. It includes all of the qualities—biological, psychological, emotional, cultural, social, and spiritual—that make people who they are. And people can express their sexuality in any of these areas; it doesn’t have to be solely through the genitals.4 Not having vaginal sex does not mean that a woman (or a man) is not being sexual. This is an important and liberating concept.
Q But how about a more satisfactory genital experience?
A Well, first you talk with each other. You tell each other how you feel. You speak of the loss, frustration, and disappointment you are feeling. You let the other person know where you’re coming from. You acknowledge that all these feelings need talking about, and you agree to work on understanding where your partner is coming from. You reiterate your love and commitment to the relationship. You state your interest in exploring new avenues, your willingness to try something new.
Q Try something new? Okay. What about anal intercourse?
A No problem if you both want to do it. But lots of women are totally turned off by the idea. Trading something painful for something repulsive is not a good deal. And by the way, if you’re going to have anal intercourse, it must be gentle and superlubricated. Rough anal intercourse can damage the anal sphincter. Once again, if it hurts, don’t do it! And vaginal entry immediately after anal sex is a total no-no.
Q What do you mean by a new way of thinking about sex?
A Researchers in sexual functioning tell us that there are two commonly held views of sexual activity. The more common view is goal-directed, which is the same as climbing a flight of stairs. The first step is kissing; the next step is caressing; then there’s vagina-penis contact, which leads to intercourse. The top step is orgasm. One or both partners has a goal in mind, and that goal is orgasm. If the sexual experience does not lead to the achievement of that goal, then the goal-directed couple or person is dissatisfied with all that has been experienced. Goal-directed sex when a woman has vulvar pain is often going to lead to dissatisfaction. That goal just isn’t possible for now.
The alternative is to go after pleasure-directed sex. Think of a circle, with each form of sexual expression merging around the edge of the circle as an end in itself. These expressions might include kissing, touching, holding, and oral sex. But each of these activities is complete in itself, and each is satisfying to the couple. There is no need for any particular form of expression to lead to anything else.

NEW HPV TESTING
Remember, the Pap test only screens for cells that don’t look right, inviting further testing to verify cervical cancer or precancer (CIN). A promising new test screens specifically for HPV, the virus that causes cervical cancer and CIN. Doctors are still debating how HPV testing should best be used. Some clinicians advocate routine HPV testing along with the Pap test. Others—including me, at least until the test’s accuracy improves—feel that HPV testing is best used to help evaluate abnormal Pap smears. The idea is that if your Pap is suspicious but your HPV test is negative for high-risk HPV, then you can be reassured that you have a low-risk virus that will probably go away on its own. If your HPV test is positive, then you can be monitored every four months for signs of problems.
The test works by looking for the DNA of the HPV virus in cervical cells obtained through a ThinPrep Pap test. (Chapter 9 discusses ThinPrep, which is basically a different way of collecting the sample.) Two different HPV tests are available. One is the FDA-approved Virapap. The other test is called polymer chain reaction (PCR).
As with the Pap, there are accuracy problems. The Virapap has a significant false-negative rate, meaning that the test can be negative when HPV is really in the sample. There are similar problems with the PCR test. One of the high-risk HPV types, type 16, can be present in women who have no evident disease. But women with a normal Pap smear and a test positive for high-risk HPV type could be tested more often to determine whether they eliminate the virus or go on to develop an abnormal Pap smear.
In 1999, a huge study of more than 46,000 women, 973 of whom had suspicious Paps, led the researchers to conclude that HPV-based testing would provide equally sensitive detection of high-grade dysplasia (HSIL), fewer colposcopy exams, and fewer follow-up visits than current practices. Furthermore, the savings from decreased visits and procedures offset the added costs of the ThinPrep method for all routine screening. Other experts emphasize the value of a negative HPV test in relieving patient anxiety and physician apprehension in the presence of an abnormal Pap. On the other hand, it’s also been argued that most women who test positive for HPV don’t have serious disease, and their positive HPV test can lead to more anxiety than a positive Pap test.
Meanwhile, HPV testing continues to improve in accuracy. A recent report shows that HPV testing is as sensitive as the Pap test for detecting HSIL. The tests are currently available for women who wish to pay for it. If you fall into a high-risk group, talk with your physician about the pros and cons of HPV testing for your particular situation.
Sources: C. J. L. M. Meijer, L. Rozendaal, J. C. van der Linden, et al., Human papillomavirus testing for primary cervical cancer screening, in New Developments in Cervical Cancer Screening and Prevention, E. Franco, J. Monsenego, eds. (Oxford: Blackwell Science, 1997), 338; J. T. Cox, A. T. Lorincz, M. H. Schiffman, et al., Human papillomavirus testing by hybrid capture appears to be useful in triaging women with cytologic diagnosis of atypical squamous cells of undetermined significance, Am J Obstet Gynecol 1995:172:946; C. P. Crum, P. T. Taylor, Intraepithelial squamous lesions of the cervix, in Gynecologic Oncology, R. C. Knapp, R. S. Berkowitz, eds. (New York: McGraw-Hill, 1993), 179; C. Bergeron, D. Jeannel, J. D. Poveda, et al., Human papillomavirus testing in women with mild cytologic atypia, Obstet Gynecol 2000:95:821; M. M. Manos, W. K. Kinney, L. B. Hurley, Identifying women with cervical neoplasia: using human papillomavirus DNA testing for equivocal Papanicolaou results, JAMA 1999:281(17):1605; B. A. Krumholz, Value of human papillomavirus testing [letter], Am J Obstet Gynecol 2000:182(2):479; R. H. Kaufman, E. Adam, Value of human papillomavirus testing [reply to letter], Am J Obstet Gynecol 2000:182(2):479; T. C. Wright, L. Denny, A. Pollack, A. Lorincz, HPV DNA testing of self-collected vaginal samples compared with cytologic screening to detect cervical cancer, JAMA 2000:283:81; L. Denny, L. Kuhn, A. Pollack, et al., Evaluation of alternative methods of cervical cancer screening for resource-poor settings, Cancer 2000:89:826.

IT’S BACK! Which Kind of UTI Is It?
Is your UTI old or new? Here are the main differences between the same old bug (a relapse) and a new kid on the block (recurrence). Either kind can be dealt with successfully.

Same Old Bug (Relapse) New Kid on the Block (Recurrence)

Original infecting bacteria, usually within
two weeks after completing therapy Different species or strain of bacteria,
usually more than two weeks after
completing therapy

If long-term (2–6 weeks) antibiotics
are not helpful, urological referral
is important Referral to urologist is not routinely
indicated; clinician may suggest a change if
the woman uses a diaphragm and spermicide

No relation to intercourse Related to intercourse

Antibiotics 2–3 times per week
for prevention Antibiotics after intercourse for
prevention; patient-initiated
therapy for symptoms