Ask Dr. Annie K.: Pain

I’m 22 years old and haven’t had sex yet. I’ve had close encounters, but every time I try I experience a lot of pain. Actually any sort of penetration brings severe pain and discomfort (tampons, fingers etc). i’ve had a basic exam from my gynecologist who reports everything is healthy and normal down there. What can I do to finally have an enjoyable sex life?

Over 75% of women experience pain from vaginal penetration at some point in their lives. You are not alone. 12% have severe pain the first time having intercourse. Many women will benefit from you asking about this very important (and painful) topic. Thank you for not being afraid to ask – Dr. Annie K is here for you.

What you are describing is called primary dyspareunia, a.k.a. painful penetration. From your gynecologic exam (which I bet was painful) it sounds like there was nothing visible externally that would indicate an infection or some kind of skin problem.

So what could it be and what to do? When it comes to painful sex, it is never “all in your head.” There is always a cause.

When I hear women talk about pain from inserting a tampon or finger as you describe, my first thought is vaginismus. Vaginismus is is considered a vagina in panic. There is an involuntary tightening of the muscles around the vagina, usually in response to penetration, or even from expecting penetration. Some women describe it as a ripping feeling or a sharp burning pressure that can last for hours or days. Anxiety is common along with frustration.

Although it may sound unusual, the first treatment recommendation is physical therapy. There are therapists specifically trained in pelvic floor anatomy. The entrance to the vagina is through pelvic floor muscles – there is no way around them! The treatment has a very high success rate in women like you who are highly motivated.

When talking sex let’s not forget the basics.

When the time comes, be sure you are with a partner you feel close to. Communication with your partner can be a game changer when a women has pain. This is a medical problem – you are working on it and sex is a priority. This may even bring you closer as a couple.

Technique is important. Allow for adequate foreplay – that part is fun! Most women achieve orgasm by stimulation of the clitoris, not penetration. No medical therapy can make up for a sexual partner who doesn’t like to play.

Lubrication can help many women who have pain with sex. Inadequate lubrication happens. It is ok to use K-Y jelly or go natural and use organic coconut oil or saliva.

Women who have experienced trauma may have painful sex as it may trigger PTSD. Work with a therapist is crucial in solving those issues and being able to move on to have a fulfilling sex life.

Whatever your age, when you have sexual pain, it can affect your self-esteem. Know that it is treatable but may take time. Start with finding the right physical therapist.

Unfortunately the first time is rarely like it looks in the movies. But it gets better! You are on your way to a healthy sex life.

Sugar, sugar

Ask Dr. Annie K:

Why do I always crave something sweet after a big meal? Even if I ate enough and I feel full it seems like there’s room for a little dessert. Is there a medical explanation for this?

“Would you like to take a look at the dessert menu?”

Someone invariably in the group says yes.

It all goes back to the primal connection between our brain and our gut – why we refer to the gut as the “Second Brain”.

We could blame it all on ghrelin . Ghrelin is known as the “hunger hormone” which is produced in the gastrointestinal tract and brain. It stimulates the appetite and signals the brain to eat. New studies show that it can keep you eating, even when you are full. Consider the potential of this hormone to lead to a major medical breakthrough in weight management. It is one of many other factors that lead to overeating.

Sugar cravings happen for 3 primary reasons:

unstable sugar levels
emotional imbalance
habit

UNSTABLE SUGAR LEVELS

Eating food that is high in sugar and carbohydrates creates a quick, sharp rise in the level of sugar in your bloodstream. Insulin – a hormone secreted by the pancreas – kicks in to control blood sugar levels. As a result, blood sugar levels drop. Then the cravings start and that tiramisu is looking better and better. The sugar/insulin rollercoaster is dangerous. Besides the damage it does to our bodies, it wrecks havoc on mood and energy levels.

EMOTIONAL EATING

Any type of unbalanced emotional state can lead to sugar craving. Stress, anxiety, anger, and sadness can trigger a need of food, for comfort. Sugary desserts produce a serotonin and dopamine rush, neurotransmitters associated with mood-elevation. Feeling unusually happy can also incite cravings. A seriously great mood makes me want to celebrate with my favorite, marshmallows ;).

HABIT

Habit is a big one. If you grew up in a house where every meal ended in dessert, you may have simply developed the habit. Dessert follows dinner, no questions asked. It may be part of a tradition in your culture. This habit is now programmed in your mind.

A habit is still a choice and that choice is yours to make.

WHAT TO DO

The dangers associated with excessive sugar intact are documented facts. Sugar has been well studied. This is not one of those findings you can rationalize by saying “one day they say eggs are good for you, the next day they are bad”. FACT: High sugar is associated with obesity, tooth decay, accelerated aging of the skin, impaired cognition in children, diabetes, cancer, heart disease, depression and dementia. Type II diabetes is an epidemic in the western world.

I am not advocating cutting out all dessert. Stressing out over dessert is also unhealthy. If you need a little something sweet keep it little. A tiny dessert will relieve the craving with way less harm than the big dessert.

Stopping Antidepressants

Fran, a 36-year-old teacher, initially presented with symptoms of major depression with anxiety. She responded well to an antidepressant and I saw her twice a year for medication management. Nine years later, we discussed stopping the medication. I gave my usual spiel, recommending a one month long taper period.
Fran called a few weeks later on the emergency number. She was sobbing – feeling terrified and anxious. She was nauseated and fuzzy. Her body felt sick, like electrical shocks were zapping her brain and limbs. She was terrified she might have MS.

These were symptoms of withdrawal. We devised an immediate plan for a slower taper. By the end, she was taking small thumbnail “chips” of the pill. It took months until she was comfortable without the medication.

While some can stop antidepressants no problem or with minimal discomfort, more than half of the patients experience withdrawal effects similar to Fran’s.

Psychiatrists knew antidepressants could not be stopped “cold turkey”. We just didn’t know how to stop them. If patients were really miserable, we simply restarted the medication, misinterpreting symptoms as a sign of relapse. Patients hated it so much they wanted the medication back, thinking this was a sign of true need. Discontinuation horror stories are all over the Internet.

Guidelines state that withdrawal reactions are self-limited and last one to two weeks. Simply untrue. Recent studies show that withdrawal reactions can be longer and more severe than initially thought. Restarting medications has lead to a dramatic increase in the length of time patients are on these drugs. How much do we know about long-term risks?

This is not unique to antidepressants. How many of you have tried to stop proton-pump inhibitors (PPIs) for acid reflux? After a few days of heartburn you reach desperately for that omeprazole without giving the body time to adjust. Furthermore, long term use of both PPIs and antidepressants are associated with neurologic diseases like dementia.

Finally doctors are paying attention. There has been a new focus on withdrawal from antidepressants which will hopefully be generalized to other drugs. Research is surfacing about how to manage a safe discontinuation.

When I prescribe antidepressants we discuss withdrawal risks from the beginning. The taper must be super slow – it can take months or years. Dr. Mark Horowitz at University College London says many people “have to pull apart their capsules and reduce the dosage bead by bead”.

I was involved in the first clinical trials for SSRIs. Those were exciting times! Finally we had safer and better tolerated weapons to beat depression. These medications have saved lives. Now we need to be just as skilled at de-prescribing as we are at prescribing them.

Ask Dr. Annie K: How Mental Health Can Affect Relationships

 

I’ve (34M) been with my girlfriend (40F) for 3.5 years and very much do still love her. I suffer from severe anxiety and PTSD but have been active in therapy for well over 15 years. My girlfriend suffers from BPD or bipolar (hasn’t been fully diagnosed yet) and unlike myself, is just starting to go through therapy and seeing a psychiatrist as well. I love her to absolute death but she’s become a very difficult person to be in a relationship with and have it not be a miserable ride.

She’ll pin me down for 2+ hours trying to explain and get me to side with some of her destructive relationship behavior. It’s very exhausting and it’s hurting our relationship. I try to give advice, but it usually doesn’t get absorbed or even listened to at all. I don’t look forward to seeing her anymore and I hate that feeling but I’m not sure how or if I can get back to the excitement of being around her again.

What do I do? Establish that we need to take a break? Break up completely? Toughen the heck up and quit being a wuss? I’m at a complete loss because even though we love each other, being her boyfriend while she’s in this state is bringing the most unhappiness I’ve ever felt in my life…

Sincerely,
A guy stuck between a rock and a hard place.

Love+Medicine

Dear Guy,

Thank you for consulting me. It is always difficult to assess the entire picture when having only one side of the story but I will offer my observations.

I am sincerely happy to hear about your own personal progress with your anxiety. You are clearly invested in treating your illness and realize how valuable it is to stay in therapy. You do not want your illness to prevent you from having a healthy, loving relationship.

If you read your letter to yourself again, you will see that the answers are there. You are clearly in love with this woman. Yet you describe yourself as experiencing “the most unhappiness I’ve ever felt in my life.”

This is understandable. Anyone who has a relationship with someone suffering from bipolar disorder knows the challenges. Your girlfriend is just now starting the healing process. It can take time to reach stability.

In the meantime, you are unhappy and this can impact your own mental stability. Giving the relationship a break may be the way to go for both sides. Your partner needs time to get healthy.

You would not be splitting because she has mental health issues. You would do it because you are miserable right now and appropriately concerned about the future.

After a period apart, you can both reassess how you are feeling. A couples counselor can be helpful particularly when confronting painful emotions – especially when facing the possibility of an end of your relationship.

Ask Dr. Annie K: B12 Injections

Love+Medicine Vitamin B12
 

Should I get a B12 shot weekly @ 65 years old?

Love+Medicine

B12 injections have been popular for decades. This is the most fun part of my job as a writer – I learn new things. While researching for this article, I have learned that I am borderline B12 deficient. Enough about me (more later). Let’s get to the facts.

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