15

MEDICAL CONDITIONS

Add low SexAbility to your list of symptoms

Up until now you may have been thinking, yes, these solutions may be the answer for other women, but I have a different problem. Perhaps you have problems from surgery . . . or heart disease . . . or diabetes . . . or multiple sclerosis . . . or any one of a number of medical conditions that might be affecting your sexual health and sexual experience. Virtually every acute or chronic disease can be accompanied by fatigue, anxiety, pain, or insomnia—all of which are culprits that can easily destroy a healthy sex life.

Anything that alters hormones, such as hypothyroidism, adrenal dysfunction, diabetes, and of course menopause, can be problematic. Hormones and neurotransmitters need to get to the right place, which is why any medical problem that compromises blood flow can have an impact on vaginal health, arousal, and orgasm. In addition, your nerves need to fire and your muscles need to contract (and relax!), which is why neurologic problems such as spinal cord injury, herniated discs, and multiple sclerosis have an impact.

To make matters even more complicated, many women have not one but two or more medical problems at the same time. Many women with heart disease also have diabetes or hypertension and are smokers. In addition, since most of these conditions are more common as women age, the majority of women are also dealing with postmenopausal hormonal changes. The drugs used to treat many disorders often create bigger problems than the illness itself.

There are over 50 medical conditions and classifications of medications that have been identified as having an impact specifically on the ability to have a normal sexual response and/or the ability to have intercourse. And over 50 percent of midlife women are coping with at least one of those issues.

Conditions and Medications That
Have an Impact on Sexual Health

Medical Conditions

Hypothyroidism

Graves’ disease

Adrenal dysfunction

Diabetes

Menopause

Spinal cord injury

Neuropathy

Herniated discs

Multiple sclerosis

Cardiovascular disease

Incontinence

Epilepsy

Hypertension

Atherosclerosis

Sickle cell disorder

Cancer

Pulmonary disease

Depression

Anxiety

Fibroids

Metabolic syndrome

Insomnia

Movement disorders

Post-traumatic stress disorder (PSTD)

Eating disorders

Parkinson’s disease

Stroke

Chronic pain

Kidney failure/dialysis

Psoriasis

Arthritis

Vascular disease

Heart failure

Pituitary tumors

Ulcerative colitis

Crohn’s disease

Anemia

Endometriosis

Adenomyosis

Pelvic organ prolapse

Interstitial cystitis

Sleep apnea

Hearing impairment

Physical disability

Surgery

Medications

Antidepressants

Anti-anxiety drugs

Antihypertensives

Antipsychotics

Hormonal contraception

Beta blockers

Lipid-lowering drugs

Histamine blockers

Narcotics

Anti-epileptic drugs

Anticholinergics

Antihistamines

Barbiturates

Comprehensive information on the impact on sexuality of each of the illnesses listed here would take up not a chapter but an encyclopedia. I discuss some of these conditions, such as endometriosis, in other chapters. I focus on the medical issues discussed in this chapter not because they are the most important, but because they are the most common conditions that have an impact on sexual health. (Cancer has its own set of issues and is covered in the next chapter.) Don’t worry if your medical issue is something other than what is discussed here—the concerns are often the same.

While every medical situation is unique, the one consistent feature is that no matter which condition you have, chances are that your doctor has not adequately addressed, or even mentioned, its impact on your sex life. For example, according to a 2013 University of Chicago study, only 35 percent of women who had a myocardial infarction (commonly called a heart attack) received information about resuming sexual activity after treatment—and then only if the patient initiated the discussion.

Heart Disease

Heart disease is the number-one killer of women in this country. It is also one of the top killers of sexual health. There are really three basic questions for women with heart disease when it comes to sex:

Issue 1: Do you have the physical strength and respiratory capacity to engage in a sexual workout?

Issue 2: Will your body have a normal sexual response such that you are able to become aroused and have a pleasurable sexual experience?

Issue 3: If you have fabulous sex and an explosive orgasm, is your heart going to be able to take it? What is the risk that if you “come,” you might “go”?

Issue 1: Do You Have the Physical Strength and Respiratory Capacity to Engage in a Sexual Workout?

Women who have a damaged or compromised heart often experience fatigue, weakness, or shortness of breath at the slightest physical activity. They may indeed have reduced capacity for some sexual activities, which is why every woman who has a condition such as congenital heart problems, severe coronary artery disease, unstable angina, vascular disease, arrhythmia, or pericarditis, or who has had heart surgery or a myocardial infarction, must be evaluated and advised individually. Keep in mind that there is a difference between what is safe to do and what you are able to do. The safety of having sex depends on the specifics of your cardiac capabilities, and while the guidelines given here are useful, you still need to check with your cardiologist. Don’t be afraid to be specific.

If your cardiologist has given you the green light but you simply feel like you don’t have the physical strength to engage in sexual activity, you may need to adjust your expectations given the reality of your limitations. You can have sex more comfortably, for instance, by using pillows and props (as addressed in chapter 6). In other words, if you don’t have the strength to prop yourself up and give oral sex for ten minutes, adapt your surroundings so that you can try, or enjoy other avenues for mutual pleasure.

Issue 2: Is Your Body Able to Have a Normal Sexual Response? Can You Become Aroused and Have a Pleasurable Sexual Experience?

Whether or not your body is capable of normal sexual response, to me, is the crux of this issue. With heart disease, it all comes down to blood flow—or more accurately, lack of blood flow. Women with coronary artery disease have plaque that builds up in blood vessels, reducing the amount of blood that is delivered to the heart. This condition is known as atherosclerosis. If there are changes in the blood vessels that supply the heart, there are also likely to be changes in the blood vessels that supply the genitals.

Reduced blood flow to the genitals may compromise genital engorgement. It’s not just about the clitoris and labia—the blood supply to the vaginal walls must also be intact if lubrication and smooth muscle relaxation are to occur. If the muscles don’t relax properly, the vagina’s ability to lengthen and dilate will be impaired.

And then there is the orgasm issue. While it’s fairly well known that men with cardiac disease often have erectile dysfunction, it’s less well appreciated that up to 50 percent of women with significant coronary artery disease have a reduced ability to reach orgasm. Of course, it makes sense that if there is limited blood flow to the clitoris, not much is going to happen. This reduction in blood flow will not only impair engorgement and keep erectile tissue from responding but also inhibit the proper flow of blood needed to ensure that nerve endings are healthy and responsive. Indeed, the impairment of clitoral blood flow in women with vascular disease has been demonstrated not only by blood flow studies but also by microscopically looking at the clitoris at the time of autopsy in women who die from heart disease. Not surprisingly, by far the worst impairment in clitoral blood flow is in women with heart disease who are also heavy smokers.

Issue 3: Is Your Heart Going to Be Able to Take Fabulous Sex and Explosive Orgasms?

Nelson Rockefeller died while having sex with his mistress. Even the mighty Attila the Hun fell victim to a heart attack that caused his early demise—on his wedding night no less. And while people might kid about a heart attack during sex being a great way to go, fear of this happening significantly reduces the amount of sexual activity of patients with known heart problems. In one study, 71 percent of women avoided sexual activity after a heart attack specifically because of their own fear or the fear of their spouse. Fear is not exactly an aphrodisiac, and it’s hard to relax or lubricate during sex if you don’t know if you are going to come . . . or go.

Other than making your heart go “pitter-patter,” what are the cardiac effects of sexual activity? Volunteers having sex in a laboratory setting (that must have been interesting!) have a significant increase in pulse, blood pressure, and respiratory rates. In other words, the heart works harder during sex, pretty much at the same level as a moderate workout.

What’s really interesting is when similar studies are conducted among married couples in their own bedrooms—heart rates don’t increase during sex! In fact, on average, married couples have heart rates that are lower during sex than the rates recorded during their normal daily activities. It’s actually somewhat depressing (and reassuring at the same time) that having sex with your spouse in your own bedroom requires only the same amount of exertion as a two- to four-mile-per-hour stroll on a level surface for a few minutes. This is probably why studies show that sexual activity is rarely responsible for a myocardial infarction. Risks are even smaller in men and women who are routinely sexually active and have regularly participated in a post-heart attack exercise program.

An article published in the Journal of the American Medical Association in 2011 confirmed this. Researchers looked at 14 studies regarding risk of cardiac death during sex. They found that death was 2.7 times more likely to occur, but only for someone who rarely had intercourse or exercised. In fact, engaging in some form of exercise once a week decreased the risk of cardiac death during sex by 45 percent. The authors concluded that the risk of death during sex with your spouse is small, especially if you exercise and/or have sex regularly.

If you continue to avoid intimacy from a fear of dying or having another heart attack, it may help to have an exercise stress test to assure you that your heart can take it. In general, most cardiologists say that you are safe to have sex with your regular partner if you can climb up two flights of stairs without having chest pain or becoming out of breath. Obviously, it’s important to check with your own doctor before initiating exercise or sex after a heart attack, but in general, patients who have no symptoms, have mild, stable angina, have controlled hypertension, and do not have exercise-induced reduced blood flow or chest pain should feel free to have sex with a partner six to eight weeks after a heart attack.

Do, however, keep this caution in mind: immediately after a heart attack is not the time to have an affair or join the mile-high club unless you are willing to suffer the fate of Nelson Rockefeller.

The Fixes

Once you are good to go and convinced that you are not going to die in the sack, it’s really disheartening if you find that things are dry and nonresponsive. Here’s what will help:

Enhance Vaginal Wall Lubrication

If your vagina isn’t responding, remember, it’s not that you are not emotionally aroused or feeling in the moment. No matter how turned on you may be, your genital blood supply may be inadequate to produce moisture right now. You need not only a good lubricant but a local vaginal estrogen as well, especially if you are peri- or postmenopausal. All of the options offered in chapter 13 are safe and appropriate if you have heart disease.

Try an Orgasm Booster

If there is nerve damage, it may take more clitoral stimulation than required in the past to achieve an orgasm. This is the time to revisit chapter 10. The fixes offered there also apply in this case. That being said, PDE5 inhibitors have been only minimally studied in women with heart disease, with mixed results, so until there is more information, it’s best to steer clear.

If you have a pacemaker, there is no reason to believe that using a vibrator will cause it to malfunction. It’s probably best, however, not to put your vibrator directly on your pacemaker.

Evaluate Your Medications

Medicines commonly prescribed to treat cardiovascular problems, such as thiazide diuretics, beta blockers, and lipid-lowering drugs (not to mention antidepressants), have generally been associated with sexual problems. However, according to a study published in the Journal of Hypertension in 2013, there are no significant associations between most antihypertensive medications and sexual dysfunction. If the sexual issues appeared at the same time you started taking a new drug, the drug might be the problem. Let your doctor know what’s happening, so you can see if there is an alternative medication.

Face the Fear Factor

Make an appointment to talk specifically to your doctor about the appropriate level of sexual activity for you. Often women will ask these questions as the doctor is headed out the door and get only a cursory answer. By letting your doctor know that this is an important issue, not just something you’re throwing out there at the end of your post-heart attack checkup, you will get more information. Exercise regularly, take off any excess weight, stop smoking if you do, and do everything else your doctor has been encouraging you to do, since not only will it save your life, it will save your sex life.

If your doctor doesn’t suggest a stress test, you might request one in order to prove to yourself that you are not going to die during sex. Bring your spouse or partner along to your appointment so that he can be reassured that you are not going to drop dead if you have a decent orgasm. Many cardiac rehab programs also have psychologists specifically trained to help you address anxiety about resuming your sex life.

Diabetes

Every diabetic woman is at risk for damage to her circulatory and nervous systems, which in turn makes every diabetic woman at risk for low libido, diminished arousal, sexual pain, and the inability to have an orgasm. While it is recognized that any woman with diabetes is likely to have some sexual issues, it’s hard to group all women with diabetes under the same umbrella. There is an enormous difference between the overweight woman who was diagnosed with type 2 diabetes at age 60 and manages her condition with oral medication and diet, on the one hand, and a type 1 diabetic who has taken insulin her entire life, on the other.

While up to 75 percent of women with type 1 diabetes report at least one sexual problem, by far the most common issue they cite is decreased vaginal lubrication. Diabetics, even if they don’t have atherosclerosis (and they often do), frequently have capillary damage. Capillaries, the smallest blood vessels, are the blood source in the vaginal wall and are therefore required to produce lubrication. This is not an estrogen issue, so even a young diabetic woman with more than adequate estrogen levels can have severe vaginal dryness. Dyspareunia becomes the norm, and decreased libido follows.

In the case of type 2 diabetes, all of these conditions apply, and more often than not other medical issues present that can affect sexuality, such as obesity and heart disease.

Vaginal Health Is a Challenge

Diabetics often have painful sex because of increased rates of vulvovaginal infection and inflammation. Candida albicans (yeast) colonize the vaginal walls of diabetics and multiply like crazy if they are surrounded by sugar, so even glucose levels that are only slightly out of balance can lead to chronic vaginal yeast infections for diabetics. In addition, decreased blood supply in the vaginal walls compromises the ability to fight off infection. And we’re not even talking about what happens once menopause hits.

Neuropathy Doesn’t Just Affect Feet

Both type 1 and type 2 diabetics, and even prediabetics, can suffer from neuropathy—nerve damage that causes pain, burning, numbness, and tingling, particularly in the feet and calves. But it’s not just the nerves in the lower extremities that are damaged; the genital nerves may be vulnerable as well.

Many diabetics have decreased genital and clitoral sensation and in some cases an inability to have an orgasm. Clitoral biopsies from diabetic women (yes, done under anesthesia) have shown abnormalities of smooth muscle cells, increased glycogen deposits, and vascular abnormalities. In other words, there is damage to not only the nerves but the blood vessels and tissue.

The Fixes

Not surprisingly, the rates of low desire in the diabetic population are sky-high. A high proportion of women with diabetes simply give up. But keep reading! If you’re diabetic, there are things you can do to keep your sexual health intact.

Control Your Blood Sugar

Add vaginal health to your already long list of reasons why tight control of glucose is critical—not only because elevated blood sugar levels increase the risk of vaginal infection, but also because out-of-control glucose increases the likelihood of damage to genital blood vessels and nerves.

Balance Your pH

An over-the-counter vaginal (not gastrointestinal) probiotic such as Pro B helps populate the vagina with healthy lactobacilli and keep things in balance. Just to be clear, a vaginal probiotic goes in your mouth, not in your vagina.

While diabetics are at increased risk for yeast infections, do not assume that every discharge is yeast. If there is a persistent odor or discharge despite treatment with an over-the-counter antifungal, see your doctor.

Use a Lubricant

Any lubricant used during intercourse, whether silicone- or water-based, should be glucose/glycogen-free. (See chapter 5 to refresh your memory.) In addition to using a lubricant to reduce friction, restoring vaginal moisture with either a long-acting moisturizer or a local vaginal estrogen is essential to reduce infection for diabetic women.

Try Vaginal Estrogen

Many diabetics are told that they can’t use estrogen because it will make their diabetes worse. It is true that oral systemic estrogens increase insulin resistance. Transdermal systemic estrogens, however, do not increase insulin resistance, nor do vaginal estrogens affect blood glucose levels. Even diabetic women who are not postmenopausal may benefit from using a local vaginal estrogen or any of the other products discussed in chapter 13.

Investigate a Device

The EROS Clitoral Therapy Device, discussed in chapter 11, has specifically been tested in diabetics, and though some data suggests that it helps increase the possibility of having orgasms, the numbers were too small to make a definitive conclusion. In any case, no negative issues have been noted. So why not give it a try?

Essentially all of the solutions discussed in chapters 5, 9, 10, and 11 are not only appropriate for diabetics but pretty much mandatory.

Metabolic Syndrome

Metabolic syndrome refers to a constellation of symptoms that indicate a predisposition for heart disease and diabetes. To be identified as having metabolic syndrome, you must have central (abdominal) obesity and at least two of the following: hypertension, elevated fasting blood sugar (but not diabetes, also known as glucose intolerance), high triglycerides, and low HDL cholesterol (the good cholesterol). While women with metabolic syndrome may not have actual heart disease, diabetes, or coronary artery disease, they are predisposed to develop those conditions. And yes, since high blood pressure, a bad lipid profile, and glucose intolerance can all damage blood vessels and impair blood flow, the impact on sexual function can be the same as in women with fully diagnosed coronary artery disease or diabetes. Many women with metabolic syndrome are also menopausal, but studies indicate that metabolic syndrome is an independent risk factor for sexual dysfunction, independent of estrogen levels.

Obese but Otherwise Healthy

Obesity is generally associated with sexual problems because it is common for obese women to have at least one medical condition that has a negative impact on their sexual health. But not every woman with a BMI over 30 (the marker for the obese range) has medical issues. It is entirely possible to be significantly overweight and have normal cardiac function, normal cholesterol, and no diabetes. In the absence of medical problems, studies are inconclusive as to the impact of obesity alone on sexuality. What is probable, however, is that obesity in some women has a direct impact on poor body image and depression, which lead in turn to impaired libido and arousal.

Incontinence

The 30 percent of adult women who suffer from some sort of incontinence, or involuntary loss of urine, are not just afraid to laugh, sneeze, cough, or run without wearing a diaper or a pad—they are also afraid to have sex. Sexual dysfunction is reported by 26 to 47 percent of women with urinary incontinence. It’s the combination of an awareness of constant odor and the fear of losing urine during intercourse that makes most women with incontinence go into avoidance mode. Eleven to 45 percent of women with incontinence lose urine during sexual intercourse, typically during penetration or orgasm—a disincentive and libido killer if there ever was one.

Stress incontinence is the loss of urine with coughing, sneezing, laughing, or anything that increases abdominal pressure. This is the incontinence that makes you grab your crotch when you cough. This is the incontinence that prevents you from playing tennis without at least considering wearing Depends. The problem with stress incontinence is that the bladder sphincter doesn’t stay closed enough to prevent urine from exiting the bladder. This is caused by weakness of the pelvic floor tissue that supports the lowest portion of the bladder where it connects to the urethra and is often brought on (though not always) by childbirth. Any increase in abdominal pressure causes the bladder neck to funnel, the urethra to droop down, and urine to escape. Pressure against the bladder and bladder neck during intercourse can also trigger urine loss.

Urge incontinence, or overactive bladder, is a sudden, irresistible urge to pee. In urge incontinence, the bladder muscles contract when they should not. The woman with urge incontinence is fine until she puts her key in the door. If she is lucky, the door will open, she won’t drop her packages, and she will make it to the toilet and get her pants down within the next four seconds. The cause of urge incontinence is not usually known, but it’s attributed most commonly to age-related changes in the urinary tract. It is also caused by bladder irritation from infection, cancer, or inflammation. Urge incontinence can also be caused by neurologic problems, such as stroke or multiple sclerosis.

It is not unusual to have elements of both stress incontinence and urge incontinence, otherwise known as mixed incontinence. (Sounds fun, right? Not!) Successful treatment of mixed incontinence depends on treating the major issue and, in some cases, both components.

Keep in mind that the same pelvic floor weakness that is responsible for urine loss may also be responsible for many of the pelvic pain syndromes discussed in chapters 8 and 9. There is a very high association between urinary issues and deep dyspareunia. So, incontinent women avoid sex not only because they might pee on their partner, but also because it hurts.

The Fixes for Stress Incontinence

Approximately 80 percent of the estimated 15 million women who suffer from stress incontinence do nothing about it because they assume that it is a normal part of aging. They often also assume that their only option is to have a surgical procedure, which inherently involves potential complications and recovery time. But common is not the same as normal, and just because something is common does not mean you have to live with it.

Once your type of incontinence has been established, treatment options can be explored. A number of nonsurgical options are available to treat women who don’t want surgery but would like to eliminate diapers, pads, and thick dark clothes as key wardrobe accessories.

Strengthen Those Muscles

The first step in the treatment of stress incontinence is to train the muscles that support the urethra and bladder. Kegel exercises have traditionally been recommended to strengthen muscles and improve the ability to hold urine. They rarely work in the woman with severe incontinence, but there can be some improvement in highly motivated women who do the exercises properly and consistently. (See chapter 6 for more information.)

Pelvic Floor Training

Total Control Programs are actually body fitness and lifestyle classes designed to strengthen the pelvic floor and abdominal wall muscles that are necessary for bladder control. Behavior modification is a key component of this comprehensive program that goes way beyond Kegels. Up to 20 percent of women who participate report that their stress incontinence symptoms are eliminated at the end of the seven-week program. For more information, go to www.totalcontrolprogram.com.

Pelvic floor muscle training with an experienced pelvic physical therapist can be highly effective. Some physical therapists also utilize electrical stimulation, with cure rates of 70 percent or more. (Go back to chapter 6 for more information on this.) Most women, however, do not have access to a pelvic physical therapist, which is why a new home device, InTone, is a welcome option. InTone is a silicone vaginal device that you get from your doctor and use at home to strengthen your pelvic floor and eliminate or greatly reduce incontinence. Once placed in the vagina, InTone is inflated to ensure comfortable but close contact with the vaginal walls. Two electrode contacts are designed to rest against pelvic muscles.

During 12-minute daily therapy sessions, a gentle electrical stimulation (the appropriate level is determined in the doctor’s office) enables you to learn to contract and relax your pelvic floor muscles. A hand-held control unit provides voice coaching and visual biofeedback. Over two to four months, as the pelvic floor muscles gain strength, the electrical stimulation is gradually increased. The electrical stimulation also trains the muscles in the wall of the bladder (known as the detrusor muscles) to relax in order to alleviate urge incontinence. Once the incontinence is eliminated, a maintenance program of one session a week keeps the muscles toned. The bonus to eliminating incontinence, of course, is possibly alleviating dyspareunia as well.

If you fail to respond to pelvic floor strengthening techniques or would simply prefer a “quick fix,” surgery will almost always correct stress incontinence. While there are many procedures, all incontinence surgeries have the common goal of correcting inadequate urethral support and restoring the urethra to its proper position. One of the most commonly done procedures is known as a TVT (tension-free vaginal tape), a urethral sling procedure that is performed on an outpatient basis. Essentially, a small piece of mesh tape that will sit underneath the urethra is inserted through a tiny vaginal incision. Over time, scar tissue forms around the tape, which “firms up” the tissue that supports the urethra. The cure rate is over 90 percent, complications such as bleeding or infection are rare, and the recovery is short. Women who have this procedure are thrilled that they no longer need to laugh with their legs crossed or worry about peeing on their partner.

The Fixes for Urge Incontinence

In contrast, the treatment of urge incontinence is never surgical, unless there is also a component of stress incontinence. While a wide range of commonly prescribed drugs are beneficial, most women are reluctant to take a medication that has side effects and is intended to be for lifelong use. Biofeedback, pelvic physical therapy, and InTone have been used very successfully for the treatment of urge incontinence and as far as I’m concerned should be the first line of treatment. Behavior modification, such as avoiding bladder irritants and urinating frequently, are commonly suggested. There are even apps for your phone that will identify not only the closest public bathroom but the cleanest!

In the meantime, empty your bladder prior to sex and, to be on the safe side, throw down a waterproof throw blanket to protect against accidents. Trust me, he won’t mind.

Fecal Incontinence

Urine is not the only thing that can leak without warning. Nothing puts a black cloud over romance like underwear with poop on it or feces on the bed. Most women have at least heard of urinary incontinence, but fecal incontinence, a reality for at least 18 million Americans, is not exactly a topic that comes up at cocktail parties. People who suffer from fecal incontinence not only don’t discuss it with family or friends but don’t even bring it up to their doctors. With no apology to the $500 million a year adult diaper industry, I happen to believe that unless there is no other solution, the only diapers adults should be buying are those for their children or grandchildren.

Fecal incontinence pretty much heads the list of taboo topics, but until we get the conversation going, women who are secretly washing their soiled underwear have no way of knowing that there are a number of solutions beyond stocking up on diapers. Colon-rectal surgeons treat fecal incontinence, but surgery is not always needed or even the best option. Pelvic floor physical therapy and biofeedback are often successful. A cutting-edge treatment now available involves the surgical placement of a pacemaker-like device that decreases or eliminates the problem. Many women who use InTone to treat urinary incontinence find that it decreases fecal incontinence as well. While this is promising, clinical trials are pending.

Crohn’s Disease and Ulcerative Colitis

Any type of inflammatory bowel disease can present challenges beyond the pain and fatigue that accompany every chronic medical problem. At the top of the list is deep pelvic pain from the same pelvic floor issues that accompany gynecologic conditions such as endometriosis. Everything in chapter 9 pertains to the woman with inflammatory bowel disease. In addition, women who have had extensive pelvic bowel surgeries can form adhesions or suffer with nerve damage, which has an impact on genital blood flow and sensation.

Sexuality and Stomas

Crohn’s disease, ulcerative colitis, and gastrointestinal cancers are but a few of the reasons why some women end up with a temporary or permanent ileostomy or colostomy. A stoma is an artificial opening on the surface of the body for the purpose of eliminating waste when the normal route is no longer viable. A plastic pouch on the abdomen holds stool (and sometimes urine) and must be emptied throughout the day.

Every woman has concerns about looking attractive to her partner. Women with a stoma are especially apprehensive, particularly with a new partner, about revealing a bag with stool hanging off their body. Add to that the fear of odor or leakage or the pouch coming off during sex.

The Fixes

Most partners don’t notice an ostomy bag any more than they notice other parts of your body. The typical sexual partner is far more interested in you than in a pouch that happens to be there. But if your bag is not an accessory you want to show off, hide it. Leave on a beautiful, long, sexy camisole or a short nightie after you slip your panties off. A tube top not only hides the pouch but also holds it in place. When you pull the tube top down just below your breasts, trust me, he won’t be looking at your pouch. Use an opaque pouch or add a cover. You can also choose positions that are not directly face to face, such as spooning or rear entry. Turn down the lights and use plenty of candles.

The pouch is odor-proof, but if you are worried, there are pouch deodorizers. Devrom is an oral tablet that removes odor from stool. (This works for anyone who worries about odor from flatulence, not just women who have ostomies.) Of course, to minimize odor or leakage concerns, empty your pouch just prior to getting things going.

Stomas can make unexpected noise, but guess what? So can a functional anus. Farting happens during lovemaking for everyone. Everyone. If your stoma has a tendency to announce itself, avoid carbonated beverages, try a little Beano to decrease gas, and turn up the music.

Surgery

Any surgical procedure can cause fatigue and pain, which in most cases are temporary. Hysterectomy is the most common major surgical procedure that women undergo and is covered in chapter 9. Issues related to menopause as a consequence of ovary removal or changes in orgasms are discussed in chapters 11, 13, and 14.

It’s not unusual for a physician to caution a patient about having sex after surgery for a particular period of time. The length of that period of time is not always based on anything scientific, nor is it always written in stone, so if you are feeling well and are interested in resuming your sex life before you have been given the official go-ahead, don’t hesitate to ask. It is also important to be specific about what you can and can’t do. Just because you are told you can’t have intercourse doesn’t mean you can’t self-stimulate or receive oral sex. If in doubt, ask your doctor. In the case of abdominal surgery, a pillow clamped on the belly is a great way to protect an incision that’s still sore.

Sometimes, particularly after orthopedic surgery, the primary issue is finding a comfortable position and protecting your new knee, hip, or shoulder. Talk about an opportunity to try new positions! If you are generally on top, trade places. Cushion your knee/hip/shoulder with a few strategically placed pillows and go for it. You may find that even after your joint or broken bone heals, the new perspective is the preferred perspective!

Sexual Dysfunction and Psychiatric Disease

Throughout this book, I have discussed the impact of depression and antidepressants on libido and arousal. It’s also important to note that a loss of libido can be the first sign of depression.

Depression is not the only psychiatric illness; women with bipolar disorders, schizophrenia or psychosis often have issues, usually directly related to medication. Many drugs that are used for treatment increase prolactin levels, a known libido-squelching hormone. Interestingly, prolactin levels do not necessarily correlate with the level of sexual dysfunction. Substitution of drugs or a PDE inhibitor may be an option, but you need to talk to your doctor on this one.

Multiple Sclerosis and Other Neuromuscular Conditions

Multiple sclerosis (MS) is a chronic disease that strikes young adults, with a predilection for women over men. This inflammatory process damages the protective coating (myelin) around nerves, causing impairment to nerve cells in the brain and spinal cord. A variety of symptoms, depending on the severity and progression of the illness, range from tremors, visual problems, fatigue, cognitive difficulties, numbness, tingling, and muscle spasticity to an inability to walk. Urinary incontinence and chronic constipation are common. So is depression.

Fortunately, most cases of MS progress very slowly, and there has been a great deal of progress in treatment, including medications to prevent attacks.

The sexual effects of MS and other neuromuscular conditions can be profound. Sensory and arousal issues are the result of neurologic damage, and there may be side effects from the medications. In addition, many women with MS are also dealing with urinary incontinence.

As a result, among women with MS:

62 percent report loss of genital sensation

33 percent report loss of orgasm

36 percent report loss of vaginal lubrication

27 percent report loss of libido

Fifty percent of adults with MS are sexually inactive.

The Fixes

The savvy woman with MS learns to plan for intimacy. Timing is everything. For many women, morning is better than evening, not only because of general fatigue issues but also because spasticity intensifies as the day goes on.

Strategies like taking a warm bath to relax muscles to reduce spasticity, taking bladder control medications, and peeing just prior to sex will reduce the chance of incontinence. In addition to the incontinence solutions discussed earlier, a beautiful waterproof throw blanket will protect both the sheets and your pride.

Make sure the room temperature is not only comfortable but conducive to nakedness! Sensitivity and muscle spasms may be alleviated by cold packs applied to the genitals. A large bag of frozen peas is not only inexpensive (and available) but molds to a crotch perfectly. EROS or the other products discussed in chapter 10 should be explored to enhance clitoral sensitivity. As with diabetes, PDE5 inhibitors seem to be helpful in women with MS.

Hormones, including estrogen, progesterone, and testosterone, seem to be protective of nerves and promote myelin formation, which is one of the reasons why some researchers think that women with MS do better than men. In fact, pregnancy, with its sky-high estrogen levels, has a positive effect on women with MS. Clinical trials are ongoing to see if estrogen, testosterone, or selective estrogen receptor modifiers are valid treatment options for MS. It stands to reason, however, that systemic hormone therapy in postmenopausal women might be beneficial. A transdermal preparation is preferable over an oral medication, not only because of its positive effects on libido but also because it reduces the blood clot risk (see chapter 14).

With or without systemic estrogen therapy, vaginal dryness caused by MS can be treated using a local vaginal estrogen or any of the other products discussed in the vaginal dryness section in chapter 13.

Arthritis

While many may not think of arthritis as an issue when it comes to sexuality, consider how difficult it is for someone with severe joint pain and limited mobility to accomplish simple day-to-day tasks such as opening jars, climbing stairs, or getting dressed. Then consider how difficult it would be for that person to get into and hold common sexual positions. Even separating their legs wide enough to have intercourse is an impossible feat for some women. Like many other medical conditions, however, arthritis is all about being creative, altering positions, and using pillows and other SexAbilitators to minimize pain or work around any mobility or strength impairments. And treat yourself to what I consider a brilliant invention: a neoprene glove that is specially designed to hold a vibrator. The glove allows a woman who cannot grasp anything to comfortably and easily self-stimulate. Genius!

Other Physical Disabilities

While true for any relationship, it is particularly important for the woman with disabilities to embrace the idea that sex is less about mechanics and more about psychological and emotional connections. Having said that, the mechanics of sexuality are a challenge for the 10 percent of the adult population with some sort of physical incapacity, whether it is severe arthritis, a spinal cord injury, missing limbs, blindness, deafness, or any other physical challenge. Sometimes, as in other gynecologic conditions, traditional intercourse is difficult or impossible and physical sexuality must be redefined in ways that are equally pleasurable. Mutual masturbation, creative masturbation, oral sex, and nongenital touching are only a few of the ways to have sexual pleasure.

In addition, planning for intimacy, as discussed before, is critical. Specific physical challenges call for disability-friendly accessories to facilitate the action. Sex doesn’t always involve a bed. If you are more comfortable in a chair, have sex in a chair. Prefer the shower? That’s what the hand-held nozzle is for. And if you want to splurge, forget the pillows and other supports and consider the Love Swing, which attaches to the ceiling and elevates you above the bed or ground. You don’t have to do a thing. Let your partner do all the work while you are gloriously suspended!

The Fixes

Review the SexAbilitators section in chapter 6 and refer to the resources section for strategies and devices to facilitate sexuality no matter what your specific physical challenge is. Sometimes all it takes is the right pillow, the right device, and a little creativity to eliminate frustration.

Hire a Helping Hand

If you have a caretaker who helps you bathe, dress, or prepare meals, add “sexual health facilitator” to that person’s job description. Expressing your need for sexual stimulation to your caregiver is not the same as expressing sexual desire for a caregiver. Be clear so your caretaker won’t be uncomfortable.

The assistant need not stay in the room, but she can certainly attach the toy to your glove or arrange pillows. And whatever you do, don’t forget to make sure the toy is charged or has fresh batteries before you send your assistant away! And, to make things even easier, invest in a vibrator with a remote control so your assistant need not even be in the same room to turn it off and on.

There is no way I can do justice to this topic in such minimal space, but fortunately a number of excellent resources are available with detailed information about enhancing sexuality in the face of physical challenges. At the top of the list is The Ultimate Guide to Sex and Disability by Miriam Kaufman, Corey Silverberg, and Fran Odette. This is a complete sex guide for people who live with disabilities, pain, illness, or chronic conditions. Whether it is chronic fatigue, back pain, spinal cord injury, hearing or visual impairment, multiple sclerosis, or pretty much any other physical issue, there is no end of websites with information and resources to help. Check out the resources section at the end of the book for a list of the many sites with inspiring ideas!