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SEXUAL PERFORMANCE PROBLEMS: VAGINISMUS AND DYSPAREUNIA

Vaginismus and Dyspareunia Two specifically female sexual problems are vaginismus and dyspareunia. These problems do not involve direct physical shutdown of any single aspect of the sexual response cycle, but they are nonetheless quite painful and frustrating.
Vaginismus is a condition in which the muscles in the outer one-third of the vaginal canal automatically spasm in reaction to any attempted vaginal penetration. This condition can vary in severity. Some women experience vaginal tightening during attempted intercourse. This proves to be uncomfortable for both partners and makes intromission (insertion of the penis into the vagina) difficult to attain. Other women experience vaginal spasms so severe that no degree of intromission is possible. Such women even have difficulty undergoing a pelvic medical examination and often find it impossible because the vaginal muscles have developed a conditioned spasm reaction to any attempts at penetration.
Vaginal spasms can often be reconditioned so that pelvic exams and intercourse are possible. Treatment for this condition typically involves learning relaxation techniques, which are used in conjunction with gradually inserting one's own fingers, or vaginal dilators of progressively larger diameters. However, some women do not experience improvement from this technique because their vaginal spasm is rooted in discomfort that is caused by physical, not psychological, factors. These factors might involve infection, a vaginal lesion, uterine pain experienced during sexual arousal, or thinning of vaginal walls secondary to aging. For such women, relaxed vaginal musculature may be possible, but pain during intercourse, or dyspareunia, may be present. Dyspareunia can be caused by psychological factors, but this condition most often signals the existence of some physical problem. The specific nature and location of pain during intercourse can provide valuable information in diagnosing the cause of dyspareunia. Does the pain occur only during deep penile penetration, or immediately upon shallow penetration? Is pain limited only to certain intercourse positions? Once lubrication occurs, does the pain lessen? The answers to these questions help a physician to accurately diagnose the cause of dyspareunia and thus to treat the condition most effectively.
If you are experiencing either vaginismus or dyspareunia, it is especially important to have a thorough gynecological examination before attempting any behavioral or psychological forms of treatment. I recommend that you seek a thorough medical evaluation as a first step in dealing with any sexual performance difficulties, and this recommendation is strongest with reference to these two conditions.
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EPILEPSY AND PREGNANCY

Women with epilepsy are quite often concerned about getting pregnant. There appear to be five reasons for this concern. They wish to know:
if they are likely to hand their epilepsy on to their children;
whether their fits will get worse during pregnancy;
whether it is safe for the baby that the mother should take anticonvulsants drugs during pregnancy;
if there will be any problems in the newborn baby from these drugs;
if they can safely breast feed the baby.
With regard to handing on epilepsy to one’s children – as mentioned earlier, if one parent has epilepsy, the chances of one of the children having epilepsy are no greater than in the population at large. If both parents have epilepsy, it would appear that the risk of a child having epilepsy is about 10 per cent. So in fact the chance of a child inheriting epilepsy, particularly idiopathic epilepsy, is negligible.
As far as seizures during pregnancy are concerned, the situation is not as clear as it might be. There is evidence that for some women, seizure control may deteriorate, while for others there may in fact be no change or even an improvement. A patient told me recently that “she would like to remain pregnant forever” as she had not had a single fit during her pregnancy, compared with six fits in the preceding nine months!
As a general working rule, it is suggested that people who have more than one grand mal fit a month are those who are most likely to have a deterioration in seizure control during pregnancy. The deterioration, if it occurs, is most likely during the first three months of pregnancy. There are a number of theories why this may happen, but none has been proved. It may be of value to check the blood anticonvulsant levels during pregnancy, especially if there is a deterioration in seizure control. The blood levels may fall, necessitating an increase in dosage during the pregnancy.
The main concern for parents is whether the anticonvulsants can harm the unborn baby (foetus). It is known by most people with epilepsy that this is a potential hazard. The effects include physical abnormalities in the baby, a process known as teratogenesis. Abnormalities have been reported in the offspring of mothers on all the commonly used anticonvulsants with the exception of carbamazepine. This is particularly applicable to phenytoin, barbiturates and sodium valproate. Babies born to mothers who have been on carbamazepine have not been shown to have any physical abnormalities, but have a smaller head size than other babies. This has not been shown to be any handicap to the babies who have been followed up for five years.
The risk of abnormalities in the baby is difficult to assess, but it seems to be most common in mothers on polytherapy (receiving numerous drugs), especially if they are on three or more anticonvulsants. The risk in mothers on phenytoin, with or without other medications, appears to be about a 10% chance of the baby showing features of the ‘foetal hydantoin’ syndrome. This syndrome consists of cleft palate, abnormalities of the fingers, possible heart abnormalities and mild mental retardation. Thus, at present, if it is possible, it would seem wise to try to change patients over to carbamazepine before conception. This may not be possible in all patients and, of course, many women will first visit their doctor when already pregnant, at which time there is no purpose in making the change.
Anticonvulsants taken by the mother during pregnancy may have some effects on the baby immediately after birth, as they are transmitted to the baby across the placenta. These include the possibility of a mild bleeding tendency and some drowsiness. In mothers who have been taking barbiturates, the infant may occasionally show features of a withdrawal reaction with irritability, jitteriness and poor sucking. None of these features is [...]

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