“Pink Viagra” for Women Coming Soon to Canada

"Who is the pretty one?" Birds in New Orleans, Louisiana. (Dr. Noorali Bharwani)
"Who is the pretty one?" Birds in New Orleans, Louisiana. (Dr. Noorali Bharwani)

Most people know that in a relationship the sexual honeymoon does not last forever. Then came along Viagra for men’s erectile dysfunction. It was soon realized that a man needs a partner who has the same kind of desire. There are many women who have difficulty with libido – also known as hypoactive sexual desire disorder. They need help as well.

Now that help is here. The US Food and Drug Administration recently (August 2015) approved flibanserin (Addyi) for the treatment of reduced sexual desire in pre-menopausal women. This should offer help in the bedrooms of North American couples.

What is hypoactive sexual desire disorder (HSDD)?

HSDD affects up to one in 10 American women. It’s characterized as an unexplained persistent lack of sexual thoughts, fantasies, responsiveness and desire to engage in sex, which causes personal distress.

What you should know about the drug flibanserin (Addyi)?

  1. It is approved for the treatment of pre-menopausal women with reduced sexual desire that causes personal distress or relationship difficulties. The medication increases the number of satisfying sexual events per month by about one half over placebo from a starting point of about two to three.
  2. Most side effects of flibanserin were mild to moderate. The most commonly reported adverse events included dizziness, nausea, feeling tired, sleepiness, and trouble sleeping.
  3. Drinking alcohol while on flibanserin may result in severely low blood pressure.
  4. Flibanserin was originally developed as an antidepressant, before being repurposed for the treatment of low sexual desire.
  5. Flibanserin should not be used to treat low sexual desire caused by co-existing psychiatric or medical problems, problems in the relationship; or low sexual desire due to medication side effects.
  6. In the U.S. physicians and pharmacies dealing with flibanserin have to undergo a certification process, while patients need to submit a written agreement to abstain from alcohol.

How does flibanserin work?

Sexual response depends on several factors and actions. Various nerve transmitters, sexual hormones and other hormones play a significant role in sexual excitation and inhibition. Among nerve transmitters, excitatory activity is driven by dopamine and norepinephrine, while inhibitory activity is driven by serotonin. The balance between these systems is of significance for a normal sexual response.

By changing serotonin and dopamine activity in certain parts of the brain, flibanserin may improve the balance between these neurotransmitter systems in the regulation of sexual response.

Flibanserin (Addyi) has been favourably received by many physicians, women’s organizations and women in general. But there are some who have reservations. People who disapprove of this medication have questioned the relevance of turning a woman into a patient if she has no interest in having sex.

Only time will tell if in the long run the “female Viagra” will create overall satisfaction and happiness in the bedrooms of the nation. As our former Prime Minister Pierre Elliott Trudeau said, “There’s no place for the state in the bedrooms of the nation.” What about the drug companies? Can they bring satisfaction and happiness in our bedrooms?

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Female Hysteria and Invention of a First Electric Vibrator

“Did you know the vibrator was the fifth domestic appliance to be electrified, after the sewing machine, fan, tea kettle and toaster? It also was invented about a decade before the vacuum cleaner and electric iron. Interesting right?” asks Brad Brevet in the online review of 2011 movie Hysteria. It was posted on his website: RopeofSilicon.com.

Now you know, an electric vibrator is a domestic appliance. Next time you buy a house, check if it is included in the price.

Seriously speaking, the movie, Hysteria, is about how female hysteria led to the invention of the vibrator. It is also a tale of a Victorian doctor who co-patents – in the name of medical science – the first electro-mechanical vibrator. It is also a story of sexual repression and woman’s liberation during the Victorian time.

Then there is a play called In the Next Room (Or The Vibrator Play). The story centers around a young male doctor at the turn of the century who innocently uses a new electric vibrator to cure a female patient of her hysteria and his wife’s discoveries about the device.

A review in the Globe and Mail says, “The film and the play are the latest incarnations to cast a bemused glance back at “hysteria,” the catch-all Victorian malady that pathologized female desire and had doctors masturbating patients, first with their hands and later with rudimentary vibrators, in hopes of treating a wide variety of symptoms, from anxiety, depression and insomnia to nymphomania and frigidity – not to mention the much frowned-upon practice of reading novels.”

Hysteria was considered a “womb disease.” It was a loosely defined condition which emerged in Hippocrates’ days (c. 460 BC – c. 370 BC) and involved “anything that made the woman troublesome to those around her.”

Generally speaking, the word hysteria describes unmanageable emotional excesses. People who are “hysterical” often lose self-control due to an overwhelming fear that may be caused by multiple events in one’s past that involved some sort of severe conflict. Until the seventeenth century, hysteria referred to a medical condition thought to be particular to women and caused by disturbances of the uterus.

Symptoms of female hysteria are various. One Victorian physician cataloged 75 pages of possible symptoms of hysteria and called the list incomplete.

The treatment of female hysteria varied. One recommendation was pregnancy to cure the symptoms, ostensibly because intercourse will “moisten” the womb and facilitate blood circulation within the body. The condition was also thought to be a sexual dysfunction. Typical treatment was massage of the patient’s genitalia by the physician and, later, by vibrators or water sprays to cause orgasm.

Manual massage by physician became a standard medical treatment in Europe at least by the 5th century AD, running through about 1900. In 1883, a British doctor, Joseph Mortimer Granville, inadvertently invents the first vibrator, known as the “Granville’s Hammer.” It was intended as a muscular massage for men.

The appearance of the mechanical vibrator relieved doctors of the drudgery of performing the massage. Some manual sessions would span close to an hour and the vibrator reduced this to mere minutes.

In Hysteria, the well-to-do women visiting Dr. Mortimer Granville’s medical clinic complain of distracting thoughts and hating their husbands. His “medical treatment” – first digital and later aided by a crude vibrator when his hands go numb – sends the women into paroxysms of pleasure and pain. People did not know much about the word “orgasm” those days.

Since then the science of Psychiatry has moved on to diagnose patients better and treat them without using a mechanical vibrator. But there is a continued fascination with the antiquated diagnosis of “female hysteria.” One explanation is that people are still uncomfortable talking about sex and sexuality. It is about failure to communicate one’s desires out of embarrassment, awkwardness or because of social issues.

To be sexually empowered is to understand your own sexuality and be comfortable with it.

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Chlamydia, Gonorrhea and Syphilis on the Rise

Recent memo from Alberta Health Services’ South Zone office warns physicians about the significant rise of sexually transmitted diseases (STD) in Southern Alberta. In 2009, Alberta reported the highest STD rates across the country. Most significant is the increase in syphilis.

In 2008, a report in the Canadian Medical Association Journal (CMAJ August 12, 2008) said that Alberta launched a $2 million campaign to combat the rise of sexually transmitted disease a day after releasing figures indicating skyrocketing rates of gonorrhea and chlamydia among young people in the province. The ads were meant to encourage condom use and regular testing for the disease. But the incidence of STD continues to rise.

STD is also on the rise in other western countries. In the United Kingdom, cases of syphilis among people aged 45 to 64 increased 139 per cent between 2002 and 2006. Cases of chlamydia rose 51 per cent.

In March 2008, U.S. Centers for Disease Control and Prevention reported that one in four teenage girls in the U.S. has a STD. An estimated 3.2 million teenage girls in that country are at risk for health problems such as infertility and cervical cancer because they have chlamydia, trichomoniasis, herpes simplex virus or human papillomavirus (causes genital warts).

Cases of syphilis have particularly increased among men having sex with men. In this group, there is also a high incidence of HIV. If a person has sex with someone who has STD then the risk of contracting the disease is extremely high. It does not matter whether a person is heterosexual or homosexual.

You are at risk of having STD if you ever had sex, if you had many sex partners, if you had sex with someone who has had many sex partners and/or you had sex without using condom.

Long term consequences of STD can be serious and sometime life threatening. Chlamydia and gonorrhea can cause pelvic inflammatory disease in women and infection of testicular area in men. This may render a person sterile. Viral warts can cause cancer of the cervix or penis. Syphilis can cause infection of the nervous system, mental problems, blindness and death. Other illnesses related to STD are hepatitis, genital herpes and AIDS.

You can lower the risk of STD by having sex with someone who is not having sex with anyone else – a monogamous relationship, who does not have STD and by always using a condom until your relationship has been established with your partner.

Primary prevention of STD can be achieved by preventing exposure by identifying at-risk individuals, performing a thorough assessment accompanied by patient-centred counselling and education and immunization when appropriate, says one of the CMAJ articles.

Secondary prevention is aimed at preventing or limiting further spread by decreasing the prevalence of STDs through detection in at-risk populations, counselling, conducting partner notification and treating infected individuals and contacts.

Practicing safe sex is the best way to stay out of trouble. Same rules apply to men and women, whether they are homosexual or heterosexual.

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Ladies, sex is safe in pregnancy.

A baby was born that was so advanced that he could talk. He looked around the delivery room and saw the doctor.
“Are you my doctor?” he asked.

“Yes, I am.”
The baby said, “Thank you for taking such good care of me during birth.”
He looked at his mother and asked, “Are you my mother?”
“Yes, I am,” she said.
“Thank you for taking such good care of me before I was born,” he said.
He then looked at his father and asked, “Are you my father?”
“Yes, I am,” his father answered.
The baby motioned him closer, then poked him repeatedly on the forehead with his index finger and said, “Hurts, doesn’t it?”

Ok, that is a joke from the Internet. Seriously speaking, pregnant women and their partners often wonder and ask their doctor if sex is allowed in pregnancy. They wonder if there are any adverse effects if they engage in sexual activity. Can sex be used to induce labour? When is it safe to have sex after delivery?

These are some of the questions discussed in an article published in the Canadian Medical Association Journal (CMAJ April 19, 2011).

Most couples engage in sexual activity during pregnancy with reduced frequency during later part of the pregnancy. Decreased sexual activity may be due to nausea, fear of miscarriage, fear of harming the fetus, lack of interest, discomfort and physical awkwardness, fear of membrane rupture, fear of infection or fatigue.

What are the likely complications if a couple engages in sexual activity during pregnancy?

Potential complications include preterm labour, pelvic inflammatory disease, and early pregnancy bleeding in placenta previa (an abnormal implantation of the placenta) and possible venous air embolism (gas bubbles in a vascular system) which is extremely rare. One study reported 18 deaths caused by venous air embolism out of 20 million pregnancies.

Generally speaking, low-risk pregnancies have no increase in the frequency of preterm labour in women who abstained from sex compared with those having sex. Women with low-risk pregnancies who have no symptoms or evidence of lower genital tract infection should be reassured that sex does not increase the risk of preterm delivery, says the CMAJ article.

Women who have a history of preterm labour, multiple gestation or cervical incompetence are considered to have high risk pregnancy. The article says that there is limited evidence to guide recommendations on sexual activity in this group.

Overall there is no evidence to support the theory that sex at term has any effect to induce spontaneous onset of labour, cesarean delivery rates or neonatal outcomes. The article says that sexual activity can be resumed after delivery as soon as the woman is comfortable and the perineal wound from episiotomy has healed. This may take two to four weeks.

So ladies, sex in pregnancy is normal. There may be some exceptional situations where one has to be careful. So there is no harm in discussing your situation with your doctor and follow the advice.

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Genital Warts Can Be Difficult To Eradicate

This is the most common sexually transmitted disease. It is estimated that one per cent of adults who are sexually active have warts in the genital or anal area. In the U.S. alone, one million people will develop genital warts each year. Of these, 25 per cent will have recurrent warts. And that is frustrating for the patient and the doctor.

Genital warts are also called condylomata acuminate or venereal warts. The warts are benign and are caused by human papillomavirus (HPV). There are at least 60 types of HPV. Genotypes six and 11 are found in over 90 per cent of cases of genital warts and genotypes 16 and 18 cause cervical cancers.

The virus is transferred from person to person or from contact with something someone has touched. In women, genital warts can grow on the outside or inside of the vagina, on the cervix, in the urethra or around the anus. In men, warts can grow on the tip or shaft of the penis, on the scrotum, in the urethra or around the anus.

How do you get genital warts?

Most, but not all, genital warts are sexually transmitted. Generally speaking warts are more common amongst people whose immune system is poor. But most people who get warts are healthy and well.

How do you know you have genital warts?

Most people with genital warts have no symptoms. By the time a person is infected and by the time the warts appear may be many months or years. The good news is most of those who get infected never develop warts.

The warts are soft fleshy lumps on or near sex organs or anus. Some people have itching or burning. Warts may be hidden in the vagina or anus.

What are the implications of the disease for patients?
The lesions are benign but they do cause psychosocial distress and may affect relationships as the warts are disfiguring and can be transmitted sexually. Genital warts also increase the incidence of cancer in the genital and anal area. Practicing safe sex is important. It is advisable to use barrier protection with new sexual partners. Condoms can reduce the risk of getting genital warts but warts can spread from areas not covered by a condom. Patients who are in stable relationship may not need barrier protection because the partner is already exposed to infection by the time patient sees a doctor.

How do we manage warts?

No specific treatment is appropriate for all patients and a person will need more than one treatment to clear the warts.

Most treatment plans will achieve clearance of virus within one to six months. In 20-30 per cent of patients new warts will occur over months or even years. Patients can treat themselves with podophyllotoxin (0.5 per cent solution or 0.15 per cent cream) and imiquimod (5 per cent cream). Imiquimod is expensive and podophyllotoxin takes longer to cure the condition.

Physicians can treat warts in the office by using trichloroacetic acid or by physical removal using cryosurgery (liquid nitrogen), electrosurgery and excision or laser treatment. In my surgical practice I use electrosurgery and/or excision.

The US Food and Drug Administration (FDA) has approved a new indication for a quadrivalent recombinant vaccine (Gardasil, Merck & Company, Inc) for the prevention of genital warts caused by human papillomavirus (HPV) types 6 and 11 in boys and men aged nine through 26 years. Since the vaccine does not cover all the viruses, about 30 percent of cervical cancers and 10 percent of genital warts will not be prevented by the current vaccines.

The HPV vaccine will not have an impact on an existing infection or any consequences of infection, such as anal and genital warts and cancerous or pre-cancerous changes that you may already have. It is very important to practice safe sex with your partner.

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Does Coffee Improve Sexual Performance?

Sex has been part of our lives since Adam and Eve decided to have a cup of coffee…ok I am just kidding. Anyway, Adam and Eve did what they had to do without the necessity of having coffee or having a smoke. They just needed and an apple. Now you won’t find an apple in anybody’s bedroom or a hotel room. Instead, you find a small coffee maker.

Coffee is known to do many things. But does it improve sexual performance?

In 1990, a paper was published in the Archives of Internal Medicine looking at sexual function in people over the age of 60 in Washtenaw County, Michigan. Their study showed that estimated proportions of individuals who were sexually active were 73.8 per cent for married men and 55.8 per cent for married women.

Among unmarried men and women the proportions were 31.1 per cent and 5.3 per cent, respectively. The levels of sexual activity decreased significantly with age in both genders. The estimated proportion of married men with erectile impotence was 35.3 per cent. The authors found that consumption of at least one cup of coffee per day was significantly associated with a higher prevalence of sexual activity in women and with a higher potency rate in men.

Ok, one cup of coffee would do the trick? Then why take the blue pill? I doubt whether coffee will ever replace your Viagra, Cialis, or Levitra. But coffee should keep you awake for awhile during sexual performance if you are in a habit of dosing off before the foreplay is over.

Scientists from Southwestern University found caffeine increased the female libido in experiments on rats. The Pharmacology, Biochemistry and Behaviour journal study said the effect was caused by it stimulating the part of the brain regulating arousal. But researchers said a similar effect was only likely to be repeated in humans who do not drink coffee regularly. Well, that study does not help much.

According to a report in the Globe and Mail (February 6, 2009), psychologists at Durham University in Britain questioned 200 people about their daily caffeine intake and whether they had ever had a hallucinatory experience.

The researchers found that hard-core coffee drinkers (those who consume an average of seven cups daily) were three times more likely to report seeing things that weren’t there, hearing voices and feeling as if they were floating above their bodies. I wonder who would like to make love to a person who has had seven cups of coffee. It would be a different kind of experience….levitational love making.

Caffeine is a mild stimulant which acts on the central nervous system and some other organs of the body. It temporarily improves concentration, alertness, reasoning, intellectual effort and vigilance. A prerequisite before love making? The stimulant effects of a small amount (say one cup of coffee) take effect after 15 – 45 minutes and last normally for about four hours.

Caffeine is readily absorbed into the bloodstream and does not accumulate in the body, being rapidly metabolized and excreted. It is interesting to know that the effects of caffeine do not last so long in smokers – nicotine doubles the speed at which caffeine is broken down in the body. Alcohol has a similar effect.

In summary, caffeine is a mild stimulant which may help with your sexual performance but do not make love to a person who has had seven or more cups of coffee. If you do then you will be singing …Love is in the air….

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Sexual Activity and Mysterious Headaches

Do you get mysterious headaches with sexual activity? May be not. But for one reader of my columns this has become a significant problem.

It is estimated that patients who have headache with sexual activity account for approximately one per cent of all headache patients. It is likely that the prevalence of this headache is underestimated, since patients often feel embarrassed to report intimate details about their sexual activities.

This condition has been given many names: benign coital headache (most of the time no serious underlying cause is found), masturbatory headache, orgasmic cephalagia (as it occurs usually at or near orgasm).

Apparently, headache related to sexual activity has been recognized since the time of Hippocrates. But the first systematic descriptions of this condition appeared in medical literature in 1974. Since then primary headache associated with sexual activity has become a well defined entity.

Coital headache is usually a recurrent, benign headache and is more common in men than in women. It can occur just before, during, or immediately after orgasm. The headaches are usually dull and throbbing and last from minutes to hours. Occasionally, some patients experience a sudden, explosive headache that occurs during orgasm.

Three types of sexual headaches are recognized.

The first, the dull type, is described as a dull ache in the head and neck that intensifies as sexual excitement increases, peaking at orgasm. This type of headache is little less common than type two.

Type two, also known as vascular or explosive coital headache, is a sudden, severe, explosive headache that occurs just before or at orgasm and persists for a few minutes to 48 hours. This is the most common type of coital headache. Patients find orgasmic headache frightening, distressing and disabling.

Type three is a postural headache, resembling that of low cerebro- spinal fluid pressure that develops after coitus. This type of headache is rare.

When patients first present with coital or orgasmic headache, it is mandatory to exclude serious underlying condition like ruptured aneurysm and bleeding in the brain. When a patient presents with a new type two coital headache of sudden onset, a CT scan should be performed, and even if this is negative, a lumbar puncture should be obtained, says one research paper.

Aneurysm without rupture can present as coital headache. To pick this condition it is necessary to do an angiography and MRI of the cerebral blood vessels. Other cause for coital headache is central nervous system vasculitis.

During the acute phase of pain, usual analgesics (ibuprofen, diclofenac, acetaminophen, ASA) can be tried but are considered of limited value to relieve the pain. In 25 per cent of the patients the pain may last more than two hours and up to 24 hours. Other medications which have been tried with some success are triptans, propranolol and indomethacin.

Fortunately, the prognosis is good and in the majority of patients where no underlying pathology is identified. With time the headaches disappear without any specific treatment.

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