Thursday, July 25, 2013

Dr. Andrea and The Cases of Post-Vasectomy Sex Pain + The Ellusive Zoloft Orgasm

Welcome to today's installment of Ask Dr. AndreaDr. Andrea is the IBWMW Doctor-at-Large, which is a good thing because the blog spends WAY too much time googling various "symptoms."

Dr. Andrea is a total bad-ass--not only because she's an osteopath at the Center for Sustainable Medicine, with specialties in women's/sexual health, nutrition and Ayurveda--but because she takes time out of her busy schedule (which I imagine involves lots of yoga and kale juice) to answer our questions.*

Dear Dr. Andrea:

I have been a reader of IBWMW for a few years. My husband and I have been together for almost 10 years – married for 6. I am 28. He is 31. He had a vasectomy in 2011. 

Our sex life is different than most (at least I think so). We are only having sex once or twice a month. I wish it was more frequent. When we do have sex I am satisfied – always able to have at least one orgasm and we try just about every position. No complaints about the actual sex.

Since his vasectomy he has slowly admitted to me that he has a lot of pain after sex. He understood it was a risk at the time of surgery. This pain has impacted our sex life in that I don’t feel he enjoys sex as I would like him to. I know that after he knows when I’m “done” he anticipates the pain and is not as hard. I think his inner monologue is something like this: “Ok. She is satisfied. Oh shit! This will be painful!”  I feel badly for him that he does not enjoy things as I do. I am extremely open to discussion but he is a bit more private when verbalizing his sexual needs.

Is there anything we can do to decrease pain? Is there something we can try to help accept the sensation of pain? Meditation? Icing? Breathing? Any insight would be very much appreciated.
Dear Anonymous- 
First off let me express my condolences- this is a tough situation. Any time sex causes pain instead of pleasure can be really difficult physically and psychologically for both partners. 
The first thing I would suggest is going to a really good Urologist- perhaps whoever did his vasectomy if he had a good rapport with the doctor. Ordinarily I would love to suggest holistic or alternative things, but post-surgery several things can happen that need to be evaluated, especially since some of them can be treated so that the pain goes away entirely. 
In the meantime, here is what is likely happening--the sperm have to go somewhere when the vas deferens is cut, so sometimes they build up in the epididymis or in the surrounding tissue and cause chronic pain. If it's happening only during sex or upon ejaculation, it could be partially a positional issue from the muscles around the testicles tensing up right before ejaculation and then the extra pressure of some sperm being released and backing up in the tube (or leaking out and irritating surrounding tissue). 
Some urologists suggest trying ibuprofen, but that would likely work best for the chronic (meaning pain all the time) version. Although it's definitely worth a try. Take the suggested dose an hour or so prior to having sex (assuming you have no allergy to ibuprofen, no stomach bleeding or irritation problems, no high blood pressure, and no kidney issues, etc... of course!) and see if it helps. 
Surgery-wise, they can go back in and clean it up, or remove the epididymis of the side that's most painful, or remove any granulomas or scar tissue that have formed that might be causing positional/ejaculation pain. 
Also, reversal of the vasectomy almost always ends the pain if it's due to one of the above issues. But that requires some definite verbalization of what you're each needing and wanting as a form of birth control and how it affects your sex life. I always try to promote positive thinking in sticky situations--perhaps this issue will help open up the dialogue between the two of you and create more pleasure on both sides. Good luck, let me know how it goes and what works!
 --Dr. Andrea

Dear Dr. Andrea:
I take 150 mg of Zoloft daily and experience the common side effect of having a harder time reaching orgasm.  I'm sure the 3 or 4 drinks I may have also had don't help.  Is there anything I can do to speed up the orgasm (for my wife's benefit, not so much mine) other than not drink?  What if I also smoke a little pot the same evening, how does that impact my issue?  Would it help if I skipped my daily Zoloft dose on the days I think I'm getting lucky?  Thanks.

Dear A.K. 
Well, it sounds like you actually know what to try first--alcohol is a depressant to the central nervous system, so that makes it responsible for around 80% of the problem here (and by the way, pot would most likely make it worse, especially since you're already combining drugs). It might help to do a trial of a week or month without alcohol and see if that made a difference consistently. Also, Zoloft isn't like Advil. The drug levels build up in the brain over 3-6 weeks, so skipping one day may have no effect, or might give you some withdrawal symptoms, rather than having a benefit, especially with the good-sized dose you're taking. There's also always Viagra (not that that helps with orgasm, but some people say it helps with arousal in general), but that brings me to the next point...

What concerns me most is it that there might be some masking of issues going on with all these nervous-system-affecting drugs you're ingesting. If you are having depression issues, alcohol is definitely going to make those issues worse, as would pot, in both the short and long term. Also, as with all intimacy challenges, there might be some other things that you could work on that would help on mental/emotional as well as physical levels (variety and experimenting with your partner can makes a big difference)... I would suggest going back to the basic first issue of why you're taking the Zoloft and see if you can't work on it a bit more intensively, which may lead to possibly decreasing your dose eventually (thus likely decreasing side effects as well). 
Another option is to shift to a medication with side effects that are not as bothersome to you--every SSRI has a different profile and one may work better for you than another. Depression can be very treatable and sometimes even resolvable, so if it were me, my goal would be to tackle it head on and see if therapy (more frequent or a different type than you've tried if you have already), mind-body techniques and/or meditation, and things like exercise and outdoor activity (again, if you already do these things, maybe a different type, more regular, or something new you've been wanting to try) might help more in combination than a medication alone. 
All of those suggestions may improve your sex life in general anyway! Either way trying more of those types of things may make it possible to at least decrease the amount of medication. Be kind to yourself, do what you can, let me know if any of these ideas help!

-Dr. Andrea
Say 'thank you' to Dr. Andrea everybody!  And remember, send questions in a comment below, an email or using the (fully operational!) contact form in the right margin.
 *(Note: This is NOT a substitute for individual medical advice or care. So if Dr. Andrea tells you to stick a rusty tin can up your butt or something, check with your doctor first. Go on, check with them. I dare you.)


The Bun said...


But seriously. I'm not quite sure how to even Google this: over the last several years, though I haven't lost the ability to orgasm (fairly easily, I'm lucky like that), I can't really feel it. Like, my body is doing stuff, but it doesn't feel good. It doesn't feel bad, either - just, unsatisfying, kind of nothing. I'm not having any numbness - just, I might as well be sneezing. This happens whether I'm with a partner or without, toys or not, drunk or sober, at home or on vacation, and so on.

I have to assume it's either related to my meds or my health problems, but I've spent time off the meds and it didn't get better, and my health is improving and that hasn't changed it any either. Currently I'm taking Wellbutrin and Flexeril for both mental health issues and fibromyalgia, as well as Zyrtec for allergies, but being off everything hasn't helped. I do suspect it started after I went on the Wellbutrin for the first time, but I can't say for sure.

Dr. Andrea, do you have any advice? Anyone else, any suggestions? And how should I phrase a search about this? I'm feeling researcher-shame here not being able to come up with anything :)

Anonymous said...

Have to disagree with your comment that alcohol makes depression worse both short and long-term. This has been scientifically disproven. It IS a way people mask depression, but that is far from the same thing.

Cheers :)

just a girl said...

How long has A.K. been taking Zoloft? I initially had similar problems from Zoloft. It took some time but, luckily, I overcame my problem. It requires patience and keeping my head "in the moment" when the time comes. A partner that accepts the fact that things might take a little longer helps, too. The other very helpful thing was lots of masturbation. I considered it training my body to respond by a highly qualified trainer. Good luck! PS I can drink and smoke and still orgasm.

Whores & Hookers said...

Actually alcohol is a stimulant in moderation, proven by every scientific study ever done. MJ is an antidepressant in moderation, hence the laughter.

I have a question too. Can a woman addicted to opiates cause a penis to go numb from pussy juice? Enquiring little heads want to know.

A.K. said...

First, thanks to Jill for submitting, and Dr. Andrea for answering, my question, and to those who have commented. Second, I'd like to address Andrea's thoughtful analysis and clarify my situation a bit.

I'm taking zoloft much more for anxiety than for depression, and I've been on it for about a year. Before, I took some other SSRI's and had the same problem with sex. My doctor switched me to zoloft because she thought it works better with grumpiness. I started at 50mg and am now at 150mg, which seems to be helping. My doctor also said that I could lower or skip a dose on days I wanted to orgasm and it should make a difference, and she was right, it did.

As for the drinking and pot, it's really just a weekend evening thing. We typically get together with 2 other families (11 kids under 11 yrs old between us - we have 3 of them) and drink a fair amount. I don't have the tolerance or desire to drink more than 4 or 5 drinks, so I'll often smoke. This relaxes and helps me in my socializing, and also makes me more accepting, or less annoyed, that my wife's sexual desire is far less than mine. Seems like a win-win, except when we do have sex it's hard for me to finish.

Regarding just a girl's suggestion to masturbate a lot, I'm concerned that if I do it too much, that will only make it harder for me to come when fucking, unless I finish myself off. Which is kind of what we're doing now, though that wasn't necessary on a night where I drank a little less and I lowered my dose for the two days before.

I guess I'll keep experimenting with the different combinations and see how it goes! :)

DrAndrea said...

Thanks for the comments everyone! Sorry for some reason I didn't see them until now! Ok, let me try to be brief but get to everyone:

The Bun: sometimes fibromyalgia comes with sensory perception issues that may be tied to sexuality, and sometimes meds help with that but sometimes they are more 'numbing' in the way you described. I would recommend sex therapy or OMing to see if you can get more in touch with your body's responses and what is going on in both your mind and emotions that may be tied with your sensation of what your body is telling you.

Anonymous: true, alcohol does not cause depression, but in some people it does worsen it, generally partly from the CNS depression it causes (after the initial stimulant effect, thanks for pointing that out W&H, very true) as well as from perhaps exacerbating or masking the problems that led to drinking in the first place- again, in Some people- others can drink and smoke till the cows come home and feel totally fantastic... my suggestions are for those they do affect.

just a girl: yes, being present is important in general for many many types of sexual issues... and everyone responds to drugs differently... some people do fine with Zoloft, some even do ok with Paxil, but others become entirely libido-less even on a 'tiny' dose... it's important to discuss side effects with your doctor whichever you're on, as there are several newer formulations that may work better for you (you = whoever's reading), and yes, the side effects can happen at any time and at any dose

W&H: I've never heard of that- if it happens please let me know! Although I would think doses high enough to cause concentrations high enough there to cause symptoms in someone else topically would be too high to allow for breathing in the person taking the medications...

AK: great! I'm so glad the lower dose worked for you. I commend you for going to a doctor and working on this. There are lots of things left to try, and I'll recommend OMing again just because I have some patients it's currently working well for, on many more levels than just sex since it's more of a meditative and connecting practice not centered on actually having an orgasm, but I encourage you to not give up- if something isn't right yet there are always more things to learn. Thanks for following up.

The Bun said...

Update 2 years later, long after anyone is still keeping up with this post I imagine, but just in case it ends up helping anyone else:

At the time, I was already familiar with OM and it hadn't helped, despite being fun. It really did feel like a physiological problem was stopping me from feeling my orgasms.

Gradually, over the last few years, I put on a bunch of weight as well, but it wasn't until a month or two ago that I made the connection that a lot of my weight problem - or at least, a lot of the overeating that was contributing to it - was because I'd lost the ability to tell when I was full until I reached the point of over-full-pain-indigestion, where I used to have a very finely-tuned sense of when to stop. I'd either stop eating too soon and be snacking 20 minutes later, or eat too much and be vaguely ill for an hour or two. I realized that this felt like the same thing - like something was stopping me from feeling neurochemical cues.

I'd read about dopamine and serotonin, and how (grossly simplified) dopamine is the drive and motivation, and serotonin is the satsifaction. And Wellbutrin works on norepinephrine, a dopamine precursor - and I've always had dopamine-related side effects while on it (the major one being hand tremors similar to a very mild form of the ones Parkinson's patients taking dopamine have). Going off the Wellbutrin never helped, but it never stopped the tremors either, so my doctor and I decided to experiment.

I've been on a half-dose of Wellbutrin and a half-dose of Zoloft for a couple of weeks now (and switching to no Wellbutrin and a full Zoloft in a few days), and both my appetite sense and my orgasms are slowly coming back online. (And the tremors are slowly going away, too.) It seems like just stopping augmenting my dopamine wasn't enough to fix things, I needed to boost my serotonin to clear the dopamine effects out (and I have depression/anxiety/a bunch of other crazy anyway in addition to the fibro, it's not like I'm just taking these things for fun). I think the good doctor was right to suggest a psych/mindfulness problem and solution - I do have ADHD as well, after all - but in my case, it's looking like the problem really wasn't in my head - it was in my brain :)

I have yet to encounter anyone else who's experienced this with Wellbutrin, either the orgasm part or the appetite part - Wellbutrin is usually considered the solution to antidepressant-induced sex problems and weight gain, not the cause. So hopefully if someone else has this problem and is coming up dry on Google like I did, this page will turn up and at least they'll know they're not crazy to think it might be the case. And I will say that if the Zoloft weren't helping ease my depression the way the Wellbutrin did, I would consider it a fair trade - less suicidal time for less sexytime is worth it, and Wellbutrin did well by me for years. I'm just glad it's looking like I may not have to make that trade after all.

in bed with married women said...

ooh, the bun, i am so happy for you. and i really hope that your answer does index decently so someone else can benefit from your discoveries. ps "a bunch of other crazy anyway"--man, i love you. xoxo

The Bun said...

aww, you're so sweet! I try to be open about my mental health stuff, because I want people to become more accepting of those kinds of things. I don't have a lot of energy for activism, but since I'm pretty non-scary and I have very little sense of privacy, being public about it feels like I'm helping, and by doing something I'd probably do anyway. I imagine it's a similar impulse to the one that keeps you coming back to post your adventures for us :) for which I'm very glad!