Human Sexuality

 

Course Objectives:                 
1.  Describe research on the anatomy and physiology of the human sexual response cycle.
2.  Describe the internal and external structures of the female reproductive system.
3.  Describe the internal and external structures of the male reproductive system.
4.  Describe and differentiate the four phases of the sexual response cycle.
5.  Identify causes, diagnosis, treatment and prevention of sexual disorders.
6.  Identify and discriminate sexually transmitted diseases.
7.  Describe sexually deviant behavior and its known causes, intervention and treatment outcomes.

 

Masters and Johnson

Human Sexuality was explored by the Masters and Johnson research team, made up of William Masters and Virginia E. Johnson. They pioneered research into the nature of human sexual response and the diagnosis and treatment of sexual disorders and dysfunctions from 1957 until the 1990s.

Their work began in the Department of Obstetrics and Gynecology at Washington University in St. Louis and was continued at the independent not-for-profit research institution they founded in St. Louis in 1964, originally called the Reproductive Biology Research Foundation and renamed the Masters & Johnson Institute in 1978.

In the initial phase of their studies, from 1957 until 1965, they recorded some of the first laboratory data on the anatomy and physiology of human sexual response based on direct observation of 382 women and 312 men in what they conservatively estimated to be "10,000 complete cycles of sexual response." Their findings, particularly on the nature of female sexual arousal (for example, describing the mechanisms of vaginal lubrication and debunking the earlier widely-held notion that vaginal lubrication originated from the cervix) and orgasm (showing that the physiology of orgasmic response was identical whether stimulation was clitoral or vaginal, and proving that women were capable of being multiorgasmic), dispelled many long standing misconceptions.

They jointly wrote two classic texts in the field, Human Sexual Response and Human Sexual Inadequacy, published in 1966 and 1970 respectively. Both of these books were best-sellers and were translated into more than thirty languages.

Research Work

Masters and Johnson met in 1957 when William Masters hired Virginia Johnson as a research assistant to undertake a comprehensive study of human sexuality. (Masters divorced his first wife to marry Johnson in 1969. They divorced three decades later, largely bringing their joint research to an end.) Previously, the study of human sexuality (sexology) had been a largely neglected area of study due to the restrictive social conventions of the time, with one notable exception.

Alfred Kinsey and his colleagues at Indiana University had previously published two volumes on sexual behavior in the human male and female in 1948 and 1953, respectively (known as the Kinsey Reports), both of which had been revolutionary and controversial in their time. Kinsey's work however, had mainly investigated the frequency with which certain behaviors occurred in the population and was based on personal interviews, not on laboratory observation. In contrast, Masters and Johnson set about to study the structure, psychology and physiology of sexual behaviour, through observing and measuring masturbation and sexual intercourse in the laboratory.

As well as recording some of the first physiological data from the human body and sex organs during sexual excitation, they also framed their findings and conclusions in language that espoused sex as a healthy and natural activity that could be enjoyed as a source of pleasure and intimacy.

 

Female Reproductive System

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction (called the ova or oocytes). The system is designed to then transport the ova to the site of fertilization where conception - the fertilization of an egg by a sperm - normally occurs in the fallopian tubes.

After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle.

What Parts Make-up the Female Anatomy?

The female reproductive anatomy includes internal and external structures.

The function of the external female reproductive structures (the genitals) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

• Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair.
• Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).
• Bartholin's glands: These glands are located beside the vaginal opening and produce a fluid (mucus) secretion.
• Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs in the female include:

• Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.
• Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.
• Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.
• Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall.

What Happens During the Menstrual Cycle?

Females of reproductive age experience cycles of hormonal activity that repeat at about one-month intervals.(Menstru means "monthly"; hence the term menstrual cycle.) With every cycle, a woman's body prepares for a potential pregnancy, whether or not that is the woman's intention. The term menstruation refers to the periodic shedding of the uterine lining.

The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase, the ovulatory phase (ovulation), and the luteal phase.

There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing hormone, estrogen and progesterone.

Follicular Phase

This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the following events occur:

• Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are released from the brain and travel in the blood to the ovaries.
• The hormones stimulate the growth of about 15-20 eggs in the ovaries each in its own "shell," called a follicle.
• These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogen.
• As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating hormone. This careful balance of hormones allows the body to limit the number of follicles that complete maturation, or growth.
• As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This dominant follicle suppresses all of the other follicles in the group. As a result, they stop growing and die. The dominant follicle continues to produce estrogen.

Ovulatory Phase

The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory phase is the midpoint of the menstrual cycle, with the next menstrual period starting about 2 weeks later. During this phase, the following events occur:

• The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain.
• This causes the dominant follicle to release its egg from the ovary.
• As the egg is released (a process called ovulation) it is captured by finger-like projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube.
• Also during this phase, there is an increase in the amount and thickness of mucous produced by the cervix (lower part of the uterus.) If a woman were to have intercourse during this time, the thick mucus captures the man's sperm, nourishes it, and helps it to move towards the egg for fertilization.

Luteal Phase

The luteal phase begins right after ovulation and involves the following processes:

• Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum.
• The corpus luteum secretes the hormone progesterone. Progesterone prepares the uterus for a fertilized egg to implant.
• If intercourse has taken place and a man's sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now considered pregnant.
• If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual period begins.

How Many Eggs Does a Woman Have?

During fetal life, there are about 6 million to 7 million eggs in the female ovaries. From this time, no new eggs are produced. The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of birth control pills, and in the presence or absence of regular menstrual cycles

Male Reproductive System

The purpose of the organs of the male reproductive system is to perform the following functions:

• To produce, maintain and transport sperm (the male reproductive cells) and protective fluid (semen)
• To discharge sperm within the female reproductive tract during sex
• To produce and secrete male sex hormones responsible for maintaining the male reproductive system

Unlike the female reproductive system, most of the male reproductive system is located outside of the body. These external structures include the penis, scrotum, and testicles.

• Penis: This is the male organ used in sexual intercourse. It has 3 parts: the root, which attaches to the wall of the abdomen; the body, or shaft; and the glans, which is the cone-shaped part at the end of the penis. The glans, also called the head of the penis, is covered with a loose layer of skin called foreskin. (This skin is sometimes removed in a procedure called circumcision.) The opening of the urethra, the tube that transports semen and urine, is at the tip of the penis. The penis also contains a number of sensitive nerve endings.

The body of the penis is cylindrical in shape and consists of 3 circular shaped chambers. These chambers are made up of special, sponge-like tissue. This tissue contains thousands of large spaces that fill with blood when the man is sexually aroused. As the penis fills with blood, it becomes rigid and erect, which allows for penetration during sexual intercourse. The skin of the penis is loose and elastic to accommodate changes in penis size during an erection.

Semen, which contains sperm (reproductive cells), is expelled (ejaculated) through the end of the penis when the man reaches sexual climax (orgasm). When the penis is erect, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.

• Scrotum: This is the loose pouch-like sac of skin that hangs behind the penis. It contains the testicles (also called testes), as well as many nerves and blood vessels. The scrotum acts as a "climate control system" for the testes. For normal sperm development, the testes must be at a temperature slightly cooler than body temperature. Special muscles in the wall of the scrotum allow it to contract and relax, moving the testicles closer to the body for warmth or farther away from the body to cool the temperature.

• Testicles (testes): These are oval organs about the size of large olives that lie in the scrotum, secured at either end by a structure called the spermatic cord. Most men have two testes. The testes are responsible for making testosterone, the primary male sex hormone, and for generating sperm. Within the testes are coiled masses of tubes called seminiferous tubules. These tubes are responsible for producing sperm cells.

The internal organs of the male reproductive system, also called accessory organs, include the following:

• Epididymis: The epididymis is a long, coiled tube that rests on the backside of each testicle. It transports and stores sperm cells that are produced in the testes. It also is the job of the epididymis to bring the sperm to maturity, since the sperm that emerge from the testes are immature and incapable of fertilization. During sexual arousal, contractions force the sperm into the vas deferens.
• Vas deferens: The vas deferens is a long, muscular tube that travels from the epididymis into the pelvic cavity, to just behind the bladder. The vas deferens transports mature sperm to the urethra, the tube that carries urine or sperm to outside of the body, in preparation for ejaculation.
• Ejaculatory ducts: These are formed by the fusion of the vas deferens and the seminal vesicles (see below). The ejaculatory ducts empty into the urethra.
• Urethra: The urethra is the tube that carries urine from the bladder to outside of the body. In males, it has the additional function of ejaculating semen when the man reaches orgasm. When the penis is erect during sex, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.
• Seminal vesicles: The seminal vesicles are sac-like pouches that attach to the vas deferens near the base of the bladder. The seminal vesicles produce a sugar-rich fluid (fructose) that provides sperm with a source of energy to help them move. The fluid of the seminal vesicles makes up most of the volume of a man's ejaculatory fluid, or ejaculate.
• Prostate gland: The prostate gland is a walnut-sized structure that is located below the urinary bladder in front of the rectum. The prostate gland contributes additional fluid to the ejaculate. Prostate fluids also help to nourish the sperm. The urethra, which carries the ejaculate to be expelled during orgasm, runs through the center of the prostate gland.
• Bulbourethral glands: Also called Cowper's glands, these are pea-sized structures located on the sides of the urethra just below the prostate gland. These glands produce a clear, slippery fluid that empties directly into the urethra. This fluid serves to lubricate the urethra and to neutralize any acidity that may be present due to residual drops of urine in the urethra.

How Does the Male Reproductive System Function?

The entire male reproductive system is dependent on hormones, which are chemicals that regulate the activity of many different types of cells or organs. The primary hormones involved in the male reproductive system are follicle-stimulating hormone, luteinizing hormone, and testosterone.

Follicle-stimulating hormone is necessary for sperm production (spermatogenesis) and luteinizing hormone stimulates the production of testosterone, which is also needed to make sperm. Testosterone is responsible for the development of male characteristics, including muscle mass and strength, fat distribution, bone mass, facial hair growth, voice change and sex drive.

How Does an Erection Occur?

The penis contains two chambers, called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa.

Erection begins with sensory and mental stimulation. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the open spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps to trap the blood in the corpora cavernosa, thereby sustaining erection. Erection is reversed when muscles in the penis contract, stopping the inflow of blood and opening outflow channels.

Sexual Response Cycle

The sexual response cycle refers to the sequence of physical and emotional changes that occur as a person becomes sexually aroused and participates in sexually stimulating activities, including intercourse and masturbation. Knowing how your body responds during each phase of the cycle can enhance your relationship and help you pinpoint the cause of any sexual problems.

What Are the Phases of the Sexual Response Cycle?

The sexual response cycle has four phases: excitement, plateau, orgasm, and resolution. Both men and women experience these phases, although the timing usually is different. For example, it is unlikely that both partners will reach orgasm at the same time. In addition, the intensity of the response and the time spent in each phase varies from person to person. Understanding these differences may help partners better understand one another's bodies and responses, and enhance the sexual experience.

Phase 1: Excitement

General characteristics of this phase, which can last from a few minutes to several hours, include the following:

• Muscle tension increases.
• Heart rate quickens and breathing is accelerated.
• Skin may become flushed (blotches of redness appear on the chest and back).
• Nipples become hardened or erect.
• Blood flow to the genitals increases, resulting in swelling of the woman's clitoris and labia minora (inner lips), and erection of the man's penis.
• Vaginal lubrication begins.
• The woman's breasts become fuller and the vaginal walls begin to swell.
• The man's testicles swell, his scrotum tightens, and he begins secreting a lubricating liquid.

Phase 2: Plateau

General characteristics of this phase, which extends to the brink of orgasm, include the following:

• The changes begun in phase 1 are intensified.
• The vagina continues to swell from increased blood flow, and the vaginal walls turn a dark purple.
• The woman's clitoris becomes highly sensitive (may even be painful to touch) and retracts under the clitoral hood to avoid direct stimulation from the penis.
• The man's testicles are withdrawn up into the scrotum.
• Breathing, heart rate, and blood pressure continue to increase.
• Muscle spasms may begin in the feet, face, and hands.
• Muscle tension increases.

Phase 3: Orgasm

This phase is the climax of the sexual response cycle. It is the shortest of the phases and generally lasts only a few seconds. General characteristics of this phase include the following:

• Involuntary muscle contractions begin.
• Blood pressure, heart rate, and breathing are at their highest rates, with a rapid intake of oxygen.
• Muscles in the feet spasm.
• There is a sudden, forceful release of sexual tension.
• In women, the muscles of the vagina contract. The uterus also undergoes rhythmic contractions.
• In men, rhythmic contractions of the muscles at the base of the penis result in the ejaculation of semen.
• A rash, or "sex flush" may appear over the entire body.

Phase 4: Resolution

During this phase, the body slowly returns to its normal level of functioning, and swelled and erect body parts return to their previous size and color. This phase is marked by a general sense of well-being, enhanced intimacy and, often, fatigue. Some women are capable of a rapid return to the orgasm phase with further sexual stimulation and may experience multiple orgasms. Men need recovery time after orgasm, called a refractory period, during which they cannot reach orgasm again. The duration of the refractory period varies among men and usually lengthens with advancing age.

Masturbation

Masturbation is the self-stimulation of the genitals to achieve sexual arousal and pleasure, usually to the point of orgasm (sexual climax). It is commonly done by touching, stroking or massaging the penis or clitoris until an orgasm is achieved. Some women also use stimulation of the vagina to masturbate or use "sex toys," such as a vibrator.

Who Masturbates?

Just about everybody. Masturbation is a very common behavior, even among people who have sexual relations with a partner. In one national study, 95% of males and 89% of females reported that they have masturbated. Masturbation is the first sexual act experienced by most males and females. In young children, masturbation is a normal part of the growing child's exploration of his or her body. Most people continue to masturbate in adulthood, and many do so throughout their lives.

Why Do People Masturbate?

In addition to feeling good, masturbation is a good way of relieving the sexual tension that can build up over time, especially for people without partners or whose partners are not willing or available for sex. Masturbation also is a safe sexual alternative for people who wish to avoid pregnancy and the dangers of sexually transmitted diseases. It also is necessary when a man must give a semen sample for infertility testing or for sperm donation. When sexual dysfunction is present in an adult, masturbation may be prescribed by a sex therapist to allow a person to experience an orgasm (often in women) or to delay its arrival (often in men).

Is Masturbation Normal?

While it once was regarded as a perversion and a sign of a mental problem, masturbation now is regarded as a normal, healthy sexual activity that is pleasant, fulfilling, acceptable and safe. It is a good way to experience sexual pleasure and can be done throughout life.

Masturbation is only considered a problem when it inhibits sexual activity with a partner, is done in public, or causes significant distress to the person. It may cause distress if it is done compulsively and/or interferes with daily life and activities.

Is Masturbation Harmful?

In general, the medical community considers masturbation to be a natural and harmless expression of sexuality for both men and women. It does not cause any physical injury or harm to the body, and can be performed in moderation throughout a person's lifetime as a part of normal sexual behavior. Some cultures and religions oppose the use of masturbation or even label it as sinful. This can lead to guilt or shame about the behavior.

Some experts suggest that masturbation can actually improve sexual health and relationships. By exploring your own body through masturbation, you can determine what is erotically pleasing to you and can share this with your partner. Some partners use mutual masturbation to discover techniques for a more satisfying sexual relationship and to add to their mutual intimacy.

Sexual Dysfuction in Men

Male Genital and Sexual Disorders

A man's genitals—the prostate gland, penis, scrotum, and testicles—are responsible for the physical aspect of sexual function. Collectively, these organs are known as the male reproductive system. The prostate gland and the penis have double duty. Because urine passes through them, they are inevitably involved in how the urinary system functions. Thus, problems with the genitals can affect sexual function or, particularly if the prostate gland or penis malfunctions, urination.

Many older men retain the ability to achieve erections, have orgasms, and ejaculate (release semen at orgasm). Nonetheless, aging itself gradually affects sexual function. Erections occur less often, do not last as long, and are less rigid. The penis becomes less sensitive to touch. After orgasm, the penis becomes limp more rapidly, and having another erection takes longer. The volume of fluid ejaculated usually decreases, and ejaculation can occur with little forewarning. Sex drive may decrease, because the level of testosterone (the main male sex hormone) decreases.

Problems with sexual function can result from disorders of the genitals, other disorders, or mental and emotional factors (such as anxiety, fear, or stress). Many sexual problems result from a combination of these factors. Men sometimes feel pressure (from themselves or a partner) to perform well sexually, and they become distressed when they cannot. This feeling is called performance anxiety. Performance anxiety can further reduce a man's ability to enjoy sexual activity.

Benign prostatic hyperplasia, prostatitis, prostate cancer, inguinal hernia, erectile dysfunction (impotence), a decreased sex drive, and ejaculation abnormalities become more common with aging. Except for prostate cancer and, very rarely, benign prostatic hyperplasia, these disorders are not life threatening. However, they can cause distress and threaten a man's self-esteem. Men may find talking about these disorders difficult and embarrassing. They may feel that the subject is off-limits for discussion, even with their doctor. But men should not let these feelings prevent them from talking with a doctor, because many of the disorders can be effectively treated.

Impotence

What Causes Impotence?

Since an erection requires a sequence of events, impotence can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area of the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of impotence. Diseases -- including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease -- account for about 70 percent of cases of impotence. Between 35 and 50 percent of men with diabetes experience impotence.

Surgery (for example, prostate surgery) can injure nerves and arteries near the penis, causing impotence. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to impotence by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

Also, many common medicines produce impotence as a side effect. These include high blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug).

Experts believe that psychological factors cause 10 to 20 percent of cases of impotence. These factors include stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure. Such factors are broadly associated with more than 80 percent of cases of impotence, usually as secondary reactions to underlying physical causes.

Other possible causes of impotence are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as insufficient testosterone.

How Is Impotence Diagnosed?
Patient History

Medical and sexual histories help define the degree and nature of impotence. A medical history can disclose diseases that lead to impotence. A simple recounting of sexual activity might distinguish between problems with erection, ejaculation, orgasm, or sexual desire.

A history of using certain prescription drugs or illegal drugs can suggest a chemical cause. Drug effects account for 25 percent of cases of impotence. Cutting back on or substituting certain medications often can alleviate the problem.

Physical Examination

A physical examination can give clues for systemic problems. For example, if the penis does not respond as expected to certain touching, a problem in the nervous system may be a cause. Abnormal secondary sex characteristics, such as hair pattern, can point to hormonal problems, which would mean the endocrine system is involved. A circulatory problem might be indicated by, for example, an aneurysm in the abdomen. And unusual characteristics of the penis itself could suggest the root of the impotence -- for example, bending of the penis during erection could be the result of Peyronie's disease.

Laboratory Tests

Several laboratory tests can help diagnose impotence. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. For cases of low sexual desire, measurement of testosterone in the blood can yield information about problems with the endocrine system.

Psychosocial Examination

A psychosocial examination, using an interview and questionnaire, reveals psychological factors. The man's sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.

How Is Impotence Treated?

Most physicians suggest that treatments for impotence proceed along a path moving from least invasive to most invasive. This means cutting back on any harmful drugs is considered first. Psychotherapy and behavior modifications are considered next, followed by vacuum devices, oral drugs, locally injected drugs, and surgically implanted devices (and, in rare cases, surgery involving veins or arteries).

Psychotherapy

Experts often treat psychologically based impotence using techniques that decrease anxiety associated with intercourse. The patient's partner can help apply the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when physical impotence is being treated.

Points to Remember

• Impotence is a consistent inability to sustain an erection sufficient for sexual intercourse.
• Impotence affects 10 to 15 million American men.
• Impotence usually has a physical cause.
• Impotence is treatable in all age groups.
• Treatments include psychotherapy, drug therapy, vacuum devices, and surgery.

Premature Ejaculation

How does ejaculation occur?

Ejaculation, controlled by the central nervous system, happens when sexual stimulation and friction provide impulses that are delivered to the spinal cord and into the brain.
Ejaculation has two phases:

Phase I: Emission

The vas deferens (the tubes that store and transport sperm from the testes) contract to squeeze the sperm toward the base of the penis through the prostate gland. The seminal vesicles release secretions that combine with the sperm to make semen. The ejaculation is unstoppable at this stage.

Phase II: Ejaculation

The muscles at the base of the penis contract forcing semen out of the penis (ejaculation and orgasm) while the bladder neck contracts. Orgasm can occur without the delivery of semen (ejaculation) from the penis. Normally, erections are lost following ejaculation.

What is premature ejaculation?

Premature ejaculation (PE) is characterized by a lack of voluntary control over ejaculation. Many men occasionally ejaculate sooner than they or their partner would like during sexual activities. PE is a frustrating problem that can reduce the enjoyment of sex, harm relationships and affect quality of life. Occasional instances of PE might not be cause for concern. However, when the problem occurs frequently and causes distress to the man or his partner, treatment may be of benefit.

What causes premature ejaculation?

Although the exact cause of premature ejaculation (PE) is not known, new studies suggest that serotonin, a natural substance produced by nerves, is important. A breakdown of the actions of serotonin in the brain may be a cause. Studies have found that high amounts of serotonin in the brain slow the time to ejaculation while low amounts of serotonin can produce a condition like PE.

Psychological factors also commonly contribute to PE. Temporary depression, stress, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence can cause PE. Interpersonal dynamics may contribute to sexual function. PE can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy.

Can premature ejaculation develop later in life?

Premature ejaculation (PE) can occur at any age. Surprisingly, aging appears not to be a cause of PE. However, the aging process typically causes changes in erectile function and ejaculation. Erections may not be as firm or as large. Erections may be maintained for a shorter period before ejaculating. The feeling that an ejaculation is about to happen may be shorter. These factors can result in an older man having an ejaculation earlier than when he was younger.

Can both premature ejaculation and erectile dysfunction affect a man at the same time?

Sometimes premature ejaculation (PE) may be a problem in men who have erectile dysfunction (ED)—the inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance. Some men do not understand that the loss of erection normally occurs after ejaculation and may wrongly complain to their doctor that they have ED when the actual problem is PE. It is recommended that the ED be treated first if you experience both ED and PE, since the PE may resolve on its own once the ED has been adequately treated.

When premature ejaculation (PE) happens so frequently that it interferes with your sexual pleasure, it becomes a medical problem requiring the care of a doctor. To understand the problem, the doctor will need to ask questions about your sexual history such as the following:

• How often does the PE occur?
• How long have you had this problem?
• Is the problem specific to one partner? Or does it happen with every partner?
• Does PE occur with all or just some attempts at sexual relations?
• How much stimulation results in PE?
• What type of sexual activity (i.e., foreplay, masturbation, intercourse, use of visual clues, etc.) is engaged in and how often?
• How has PE affected sexual activity?
• What is the quality of your personal relationships?
• How does PE affect your quality of life?
• Are there any factors that make PE worse or better (i.e., drugs, alcohol, etc.)?

 

Usually, laboratory testing is not necessary unless the history and a physical examination reveal something more complicated.

Sexual Dysfunction in Women
 
Dyspareunia is pain during sexual intercourse.

The pain of dyspareunia may be superficial, occurring in the genital area (in the vulva, including the opening of the vagina), or deep, occurring within the pelvis due to pressure on internal organs. The pain may be burning, sharp, or cramping.

Superficial pain during sexual intercourse has many causes. When women have sexual intercourse the first time, the membrane that covers the opening of the vagina (hymen), if still intact, may tear as the penis enters the vagina, causing pain and sometimes bleeding. When the vagina is inadequately lubricated, intercourse may be painful. (Inadequate lubrication usually results from insufficient foreplay or from the decrease in estrogen levels after menopause.) Inflammation or infection in the genital area (for example, affecting the vulva, vagina, or Bartholin's glands) or in the urinary tract can make intercourse painful. Herpes can cause severe genital pain. Other causes include injuries in the genital area, a diaphragm or cervical cap that does not fit properly, an allergic reaction to contraceptive foams or jellies or to latex condoms, a congenital abnormality (such as a rigid hymen or an abnormal wall within the vagina), and involuntary contraction of the vaginal muscles (vaginismus). Sexual intercourse may be painful for women who have had surgery that narrows the vagina (for example, to repair tissues torn during childbirth or to correct a pelvic floor disorder (see Pelvic Floor Disorders). Taking antihistamines can cause slight, temporary dryness of the vagina. During breastfeeding, the vagina may become dry because estrogen levels are low.

As women age, the lining of the vagina thins and becomes dry because estrogen levels decrease. This condition is called atrophic vaginitis. As a result, intercourse may be painful.

Deep pain after sexual intercourse may result from an infection of the cervix, uterus, or fallopian tubes. Other causes include endometriosis, pelvic inflammatory disease (including pelvic abscess), pelvic tumors (including ovarian cysts), and bands of scar tissue (adhesions) that have formed between organs in the pelvis after an infection or surgery. Sometimes one of these disorders results in the uterus bending backward (retroversion). The ligaments, muscles, and other tissues that hold the uterus in place may weaken, resulting in the uterus dropping down toward the vagina (prolapse (see When the Bottom Falls Out: Prolapse in the Pelvis). Such changes in position can result in pain during intercourse. Radiation therapy for cancer may cause changes in the tissues that make intercourse painful.

Psychologic factors can cause superficial or deep pain. Examples are anger or repulsion toward a sex partner, fear of intimacy or pregnancy, a negative self-image, and a traumatic sexual experience (including rape). However, psychologic factors may be difficult to identify.

Diagnosis and Treatment

The diagnosis is based on symptoms: when and where the pain occurs and when intercourse began to be painful. To try to identify the cause, a doctor asks the woman about her medical and sexual history and performs a pelvic examination.

Women should abstain from intercourse until the problem resolves. However, sexual activity that does not involve vaginal penetration can continue.

Superficial pain can be reduced by applying an anesthetic ointment and by taking sitz baths. Liberally applying a lubricant before intercourse may help. Water-based lubricants rather than petroleum jelly or other oil-based lubricants are preferable. Oil-based products tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. Spending more time in foreplay may increase vaginal lubrication. Deep pain may be reduced by using a different position for intercourse. For example, a position that gives the woman more control of penetration (such as being on top) or that involves less deep thrusting may help.

More specific treatment depends on the cause. If the cause is thinning and drying of the vagina after menopause, using a topical estrogen cream or suppository or taking estrogen by mouth (as part of hormone therapy (see Menopause: Hormone Therapy) can help.

Inflammation and infection are treated with antibiotics, antifungal drugs, and other drugs as appropriate (see Some Vaginal Infections). If the cause is inflammation of the vulva (vulvitis), applying wet dressings of aluminum acetate solution may help. Surgery may be needed to remove cysts or abscesses, open a rigid hymen, or repair an anatomic abnormality. A poorly fitting diaphragm should be replaced with one that fits and is comfortable, or a different method of birth control should be tried.

If the cause of pain is the position of the uterus, a pessary, which resembles a diaphragm and is inserted into the vagina, can support and reposition the uterus. Using a pessary reduces the pain in some women.

 Orgasmic disorder is the delay in or absence of sexual climax (orgasm) despite sufficiently long and intense sexual stimulation.

The amount and type of stimulation required for orgasm varies greatly from woman to woman. Most women can reach orgasm when the clitoris is stimulated, but only about half of women regularly reach orgasm during sexual intercourse. About 1 of 10 women never reach orgasm. Orgasmic disorder occurs when problems with orgasm are persistent and frequent, interfering with sexual function and causing distress.

Usually, women who have learned how to reach orgasm do not lose that ability unless poor sexual communication, conflict in a relationship, a traumatic experience, or a physical or psychologic disorder intervenes. Physical and psychologic causes are similar to those of sexual arousal disorder. Depression is a common cause.

Orgasmic disorder may result from lovemaking that consistently ends before the woman reaches orgasm. The woman may not reach orgasm because foreplay is inadequate, because one or both partners do not understand how the genital organs function, or because ejaculation is premature. Such lovemaking produces frustration and may result in resentment and occasionally in distaste for anything sexual. Some women who become aroused may not reach orgasm because they fear "letting go," especially during intercourse. This fear may be due to guilt after a pleasurable experience, fear of abandoning oneself to pleasure that depends on the partner, or fear of losing control.

Certain drugs, particularly selective serotonin reuptake inhibitors may inhibit orgasm.

Orgasmic disorder may be temporary, may occur after years of normal sexual function, or may be lifelong. It may occur all the time or only in certain situations. Most women who have a problem reaching orgasm also have a problem being aroused.

Diagnosis and Treatment

The diagnosis is based on the woman's description of the problem. To identify the cause, a doctor asks the woman about her sexual and medical history, including use of drugs, and performs a physical examination.

If the cause is psychologic, counseling for the woman, usually with her partner, often helps. Psychotherapy for the woman or the couple may be recommended. Physical disorders, if present, are treated.

Other useful measures include sensate focus exercises for couples, information about how the genital organs function, and Kegel exercises.

Sexual arousal disorder is the persistent or recurring inability to attain or to maintain adequate vaginal lubrication and other physical responses of sexual excitement before or during sexual intercourse.

Usually, when a woman is sexually stimulated, the vagina releases lubricating secretions, the labia and clitoris of the vulva swell, and the breasts enlarge slightly. In sexual arousal disorder, these responses do not occur despite sufficiently long and intense sexual stimulation.

If the disorder has been present since puberty, the woman may not know how the genital organs (particularly the clitoris) function or what arousal techniques are effective. The lack of knowledge leads to anxiety, which worsens the problem. Many women who have sexual arousal disorder associate sex with sinfulness and sexual pleasure with guilt. Fear of intimacy and a negative self-image may also contribute.
If the disorder develops after a period of adequate sexual functioning, it may be due to a problem in the current sexual relationship, such as constant fighting or arguing. Depression is a common cause, and stress may contribute.

Physical causes include inflammation of the vagina (vaginitis), inflammation of the bladder (cystitis), endometriosis, an underactive thyroid gland (hypothyroidism), diabetes mellitus, multiple sclerosis, and muscular dystrophy.

Sexual arousal disorder may develop as women age. As menopause approaches, the lining of the vagina thins and becomes dry because the estrogen level decreases. As a result, the ability to become aroused declines, partly because sexual intercourse may be painful.

Taking drugs such as oral contraceptives, antihypertensives, antidepressants, or sedatives can cause sexual arousal disorder. Surgical removal of the uterus (hysterectomy) or breast (mastectomy) may damage a woman's sexual self-image, contributing to sexual arousal disorder.

Many women with sexual arousal disorder also lack sexual desire. Because the vagina does not become lubricated, sexual intercourse is usually painful or uncomfortable.

Diagnosis and Treatment

The diagnosis is based on the woman's description of the problem. To determine the severity of the disorder and identify the cause, a doctor asks the woman about her sexual and medical history (including use of drugs) and performs a physical examination. Tests to detect physical disorders, if thought to be the cause, may be performed.

If the cause is psychologic, counseling for the woman, usually with her partner, often helps. Individual psychotherapy or group therapy is sometimes useful. Physical disorders, if present, are treated. Postmenopausal women may benefit from treatment with estrogen or male hormones such as testosterone. Estrogen creams and suppositories reduce the thinning and drying of the lining of the vagina and thus may help with lubrication during intercourse. The use of in treating women with sexual arousal disorder is controversial.

Sensate focus exercises for couples can help relieve a couple's anxiety about intimacy and sexual intercourse. Learning about how the genital organs function can help. A woman can learn which arousal techniques are effective for her and her partner. Performing Kegel exercises can help because they strengthen the muscles involved in sexual intercourse.

Vaginismus is an involuntary contraction of muscles around the opening of the vagina that makes sexual intercourse painful or impossible.

Vaginismus may result from a woman's unconscious desire to prevent sexual intercourse. Pain experienced in the past during sexual intercourse can lead to vaginismus. Other reasons women do not want to engage in intercourse include fear of becoming pregnant, of being controlled by their partner, or of losing control. Sometimes vaginismus is caused by a physical disorder, such as a pelvic infection or scarring of the vaginal opening (due to injury, childbirth, or surgery). Irritation (due to douches, spermicides, or latex in condoms) may also cause vaginismus.

Because of the pain, some women who have vaginismus cannot tolerate sexual intercourse (that is, penetration of the vagina by the penis). However, sexual activity that does not involve penetration may be pleasurable. Some women cannot tolerate the insertion of a tampon and may need an anesthetic when a doctor performs a pelvic examination.

Diagnosis and Treatment

The diagnosis is based on the woman's description of the problem, her medical history, and the physical examination, including her reaction to a pelvic examination.

Physical disorders that may be causing or contributing to vaginismus are treated. If the cause is psychologic, counseling for the woman and her partner is usually helpful.

If vaginismus persists, the woman is taught a technique to relax the muscle spasms. The technique involves gradually widening (dilating) the vagina. The woman begins by inserting very small, lubricated plastic rods (dilators) into her vagina. The woman inserts slightly but progressively larger dilators as her level of comfort increases. Once the woman can tolerate having large dilators inserted without discomfort, she and her partner may try to have sexual intercourse again.

Kegel exercises, which strengthen the pelvic muscles, can be helpful if performed while the dilators are in place. For these exercises, the muscles around the vagina, urethra, and rectum—the muscles used to stop the flow of urine—are repeatedly squeezed hard and then relaxed 10 to 20 times. Performing the exercises several times a day is recommended. These exercises enable the woman to develop a sense of control over the muscles that were contracting involuntarily.

Sex Therapy: Sensate Focus Technique

The sensate focus technique may help couples that are having sexual difficulties because of psychologic rather than physical factors. The technique aims to make both partners aware of what each finds pleasurable and to reduce anxiety about performance. It is often used in the treatment of decreased libido, sexual arousal disorder, orgasmic disorder, and erectile dysfunction (impotence).
The technique has three steps. Both partners must become comfortable at each level of intimacy before proceeding to the next step.

• The first step focuses on the sensation of touching, rather than the likelihood of sexual arousal or intercourse. Each partner takes turns touching any part of the other's body, except the genitals and breasts.
• The second step allows partners to touch any part of the other's body, including the genitals and breasts. However, the focus remains the same—on the sensation of touching, not on sexual response. Intercourse is not allowed.
• The third step involves mutual touching, eventually leading to sexual intercourse as the couple becomes more comfortable with touching and being touched. The focus is on enjoyment rather than on orgasm.

Kegel Exercises: Squeeze and Relax

Kegel exercises help strengthen the pelvic muscles, primarily those around the vagina, urethra, and rectum. Performing them regularly can help improve sexual function and prevent or reduce the involuntary loss of urine (urinary incontinence) or stool (fecal incontinence).

To perform these exercises, a woman squeezes the muscles used to stop the flow of urine for about 10 seconds, then relaxes for 10 seconds. The exercise is repeated 10 to 20 times in a row at least 3 times a day. Muscle tone usually improves in 2 to 3 months. Kegel exercises can be performed anywhere, whether a woman is sitting, standing, or lying down.

Finding the right muscles to squeeze can be difficult. The muscles can be identified by inserting a finger into the vagina and squeezing or by trying to stop the flow of urine. If pressure is felt around the finger or urine flow stops, the right muscles are being squeezed.

Pregnancy

A baby goes through several stages of development, beginning as a fertilized egg. The egg develops into a blastocyst, an embryo, then a fetus.

Fertilization

During each normal menstrual cycle, one egg (ovum) is usually released from one of the ovaries, about 14 days before the next menstrual period. Release of the egg is called ovulation. The egg is swept into the funnel-shaped end of one of the fallopian tubes.

At ovulation, the mucus in the cervix becomes more fluid and more elastic, allowing sperm to enter the uterus rapidly. Within 5 minutes, sperm may move from the vagina, through the cervix into the uterus, and to the funnel-shaped end of a fallopian tube—the usual site of fertilization. The cells lining the fallopian tube facilitate fertilization.

If a sperm penetrates the egg, fertilization results. Tiny hairlike cilia lining the fallopian tube propel the fertilized egg (zygote) through the tube toward the uterus. The cells of the zygote divide repeatedly as the zygote moves down the fallopian tube. The zygote enters the uterus in 3 to 5 days. In the uterus, the cells continue to divide, becoming a hollow ball of cells called a blastocyst. If fertilization does not occur, the egg degenerates and passes through the uterus with the next menstrual period.

If more than one egg is released and fertilized, the pregnancy involves more than one fetus, usually two (twins). Such twins are fraternal. Identical twins result when one fertilized egg separates into two embryos after it has begun to divide.

Development of the Blastocyst

Between 5 and 8 days after fertilization, the blastocyst attaches to the lining of the uterus, usually near the top. This process, called implantation, is completed by day 9 or 10.

The wall of the blastocyst is one cell thick except in one area, where it is three to four cells thick. The inner cells in the thickened area develop into the embryo, and the outer cells burrow into the wall of the uterus and develop into the placenta. The placenta produces several hormones that help maintain the pregnancy. For example, the placenta produces human chorionic gonadotropin, which prevents the ovaries from releasing eggs and stimulates the ovaries to produce estrogen and progesterone continuously. The placenta also carries oxygen and nutrients from mother to fetus and waste materials from fetus to mother.

The wall of the blastocyst becomes the outer layer of membranes (chorion) surrounding the embryo. An inner layer of membranes (amnion) develops by about day 10 to 12, forming the amniotic sac. The amniotic sac fills with a clear liquid (amniotic fluid) and expands to envelop the developing embryo, which floats within it.

As the placenta develops, it extends tiny hairlike projections (villi) into the wall of the uterus. The projections branch and rebranch in a complicated treelike arrangement. This arrangement greatly increases the area of contact between the wall of the uterus and the placenta, so that more nutrients and waste materials can be exchanged. The placenta is fully formed by 18 to 20 weeks but continues to grow throughout pregnancy. At delivery, it weighs about 1 pound.

Development of the Embryo

The next stage in development is the embryo, which develops under the lining of the uterus on one side. This stage is characterized by the formation of most internal organs and external body structures. Organ formation begins about 3 weeks after fertilization, when the embryo is first recognizable as having a human shape. Shortly thereafter, the area that will become the brain and spinal cord (neural tube) begins to develop. The heart and major blood vessels begin to develop by about day 16 or 17. The heart begins to pump fluid through blood vessels by day 20, and the first red blood cells appear the next day. Blood vessels continue to develop in the embryo and placenta.

= Once a month, an egg is released from an ovary into a fallopian tube. After sexual intercourse, sperm move from the vagina through the cervix and uterus to the fallopian tubes, where one sperm fertilizes the egg. The fertilized egg (zygote) divides repeatedly as it moves down the fallopian tube to the uterus. First, the zygote becomes a solid ball of cells. Then it becomes a hollow ball of cells called a blastocyst. Inside the uterus, the blastocyst implants in the wall of the uterus, where it develops into an embryo attached to a placenta and surrounded by fluid-filled membranes.

Almost all organs are completely formed by about 8 weeks after fertilization (which equals 10 weeks of pregnancy). The exceptions are the brain and spinal cord, which continue to mature throughout pregnancy. Most malformations occur during the period when organs are forming. During this period, the embryo is most vulnerable to the effects of drugs, radiation, and viruses. Therefore, a pregnant woman should not be given any live-virus vaccinations or take any drugs during this period unless they are considered essential to protect her health.

Development of the Fetus

Placenta and Embryo at 8 Weeks

At the end of the 8th week after fertilization (10 weeks of pregnancy), the embryo is considered a fetus. During this stage, the structures that have already formed grow and develop. By 12 weeks of pregnancy, the fetus fills the entire uterus. By about 14 weeks, the sex can be identified. Typically, the pregnant woman can feel the fetus moving at about 16 to 20 weeks. Women who have been pregnant before typically feel movements about 2 weeks earlier than women who are pregnant for the first time. By about 23 to 24 weeks, the fetus has a chance of survival outside the uterus.

The lungs continue to mature until near the time of delivery. The brain accumulates new cells throughout pregnancy and the first year of life after birth.

At 8 weeks of pregnancy, the placenta and fetus have been developing for 6 weeks. The placenta forms tiny hairlike projections (villi) that extend into the wall of the uterus. Blood vessels from the embryo, which pass through the umbilical cord to the placenta, develop in the villi. A thin membrane separates the embryo's blood in the villi from the mother's blood that flows through the space surrounding the villi (intervillous space). This arrangement allows materials to be exchanged between the blood of the mother and that of the embryo.

The embryo floats in fluid (amniotic fluid), which is contained in a sac (amniotic sac). The amniotic fluid provides a space in which the embryo can grow freely. The fluid also helps protect the embryo from injury. The amniotic sac is strong and resilient.

Pregnancy causes many changes in a woman's body. Most of them disappear after delivery. In some women, certain disorders, such as a skin rash or gestational diabetes, develop during pregnancy. Some symptoms should be immediately reported to a doctor if they occur during pregnancy. They include the following:

• persistent headaches
• persistent nausea and vomiting
• dizziness
• disturbances of eyesight
• pain or cramps in the lower abdomen
• contractions
• vaginal bleeding
• leakage of amniotic fluid (described as "the water breaks")
• swelling of the hands or feet
• decreased or increased urine production
• any illness or infection

General Health: Fatigue is common, especially in the first 12 weeks and again in late pregnancy. Getting enough rest is important.

Reproductive Tract: By 12 weeks of pregnancy, the enlarging uterus may cause the woman's abdomen to protrude slightly. The uterus continues to enlarge throughout pregnancy. The enlarging uterus extends to the level of the navel by 20 weeks and to the lower edge of the rib cage by 36 weeks.

The amount of normal vaginal discharge, which is clear or whitish, commonly increases. This increase is usually normal. However, if the discharge has an unusual color or smell or is accompanied by vaginal itching and burning, a woman should see her doctor. Such symptoms may indicate a vaginal infection. Some vaginal infections, such as trichomoniasis (a protozoan infection) and candidiasis (a yeast infection), are common during pregnancy and can be easily treated Breasts: The breasts tend to enlarge because hormones (mainly estrogen) are preparing the breasts for milk production. The breasts enlarge because the glands that produce milk gradually increase in number and become able to produce milk. The breasts may feel firm and tender. Wearing a bra that fits properly and provides support may help.

During the last weeks of pregnancy, the breasts may produce a thin, yellowish or milky discharge (colostrum). Colostrum is also produced during the first few days after delivery, before breast milk is produced. This fluid, which is rich in minerals and antibodies, is the breastfed baby's first food.

Heart and Blood Flow: During pregnancy, the woman's heart must work harder because as the fetus grows, the heart must pump more blood to the uterus. By the end of pregnancy, the uterus is receiving one fifth of the woman's blood supply. During pregnancy, the amount of blood pumped by the heart (cardiac output) increases by 30 to 50%. As cardiac output increases, the heart rate at rest speeds up from a normal prepregnancy rate of about 70 beats per minute to 80 or 90 beats per minute. During exercise, cardiac output and heart rate increase more when a woman is pregnant than when she is not. During labor, cardiac output increases by an additional 10%. After delivery, cardiac output decreases rapidly at first, then more slowly. It returns to the prepregnancy level about 6 weeks after delivery.

Certain heart murmurs and irregularities in heart rhythm may appear because the heart is working harder. Sometimes a pregnant woman may feel these irregularities. Such changes are normal during pregnancy. However, certain abnormal heart rhythms, which occur more often in pregnant women, may require treatment.

Blood pressure usually decreases during the 2nd trimester but may return to a normal prepregnancy level in the 3rd trimester.

The volume of blood increases by 50% during pregnancy. The amount of fluid in the blood increases more than the number of red blood cells (which carry oxygen). The result is mild anemia, which is normal. For reasons not clearly understood, the number of white blood cells (which fight infection) increases slightly during pregnancy and markedly during labor and the first few days after delivery.

The enlarging uterus interferes with the return of blood from the legs and the pelvic area to the heart. As a result, swelling (edema) is common, especially in the legs. Varicose veins commonly develop in the legs and in the area around the vaginal opening (vulva), sometimes causing discomfort. Clothing that is loose around the waist and legs is more comfortable and does not restrict blood flow. Wearing elastic support hose, resting frequently with the legs elevated, or lying on the left side usually reduces leg swelling and may ease the discomfort caused by varicose veins. Varicose veins may disappear after delivery.

Urinary Tract: Like the heart, the kidneys work harder throughout pregnancy. They filter the increasing volume of blood. The volume of blood filtered by the kidneys reaches a maximum between 16 and 24 weeks and remains at the maximum until immediately before delivery. Then, pressure from the enlarging uterus may slightly decrease the blood supply to the kidneys.

The activity of the kidneys normally increases when a person lies down and decreases when a person stands. This difference is amplified during pregnancy—one reason a pregnant woman needs to urinate frequently while trying to sleep. Late in pregnancy, lying on the side, particularly the left side, increases kidney activity more than lying on the back. Lying on the left side relieves the pressure that the enlarged uterus puts on the main vein that carries blood from the legs. As a result, blood flow improves and kidney activity increases.

The uterus presses on the bladder, reducing its size so that it fills with urine more quickly than usual. This pressure also makes a pregnant woman need to urinate more often and more urgently.

Respiratory Tract: The increased production of the hormone progesterone signals the brain to lower the level of carbon dioxide in the blood. As a result, a pregnant woman breathes faster and more deeply to exhale more carbon dioxide and keep the carbon dioxide level low. The circumference of the woman's chest enlarges slightly.

Virtually every pregnant woman becomes somewhat more out of breath when she exerts herself, especially toward the end of pregnancy. During exercise, the breathing rate increases more when a woman is pregnant than when she is not.

Because more blood is being pumped, the lining of the airways receives more blood and swells somewhat, narrowing the airways. As a result, the nose occasionally feels stuffy, and the eustachian tubes (which connect the middle ear and back of the nose) may become blocked. The tone and quality of the woman's voice may change slightly.

Digestive Tract: Nausea and vomiting, particularly in the mornings (morning sickness), are common. They may be caused by the high levels of estrogen and human chorionic gonadotropin (HCG), two hormones that help maintain the pregnancy. Nausea and vomiting may be relieved by changing the diet or patterns of eating. For example, drinking and eating small portions frequently, eating before getting hungry, and eating bland foods (such as bouillon, consommé, rice, and pasta) may help. Eating plain soda crackers and sipping a carbonated drink may relieve nausea. Keeping crackers by the bed and eating one or two before getting up may relieve morning sickness. No drugs specifically designed to treat morning sickness are currently available. If nausea and vomiting are so intense or persistent that dehydration, weight loss, or other problems develop, a woman may need to be treated with antiemetic drugs or be hospitalized temporarily and given fluids intravenously Heartburn and belching are common, possibly because food remains in the stomach longer and because the ringlike muscle (sphincter) at the lower end of the esophagus tends to relax, allowing the stomach's contents to flow backward into the esophagus. Heartburn can be relieved by eating smaller meals, by not bending or lying flat for several hours after eating, and by taking antacids. However, the antacid sodium bicarbonate should not be used because it contains so much salt (sodium). Heartburn during the night can be relieved by not eating for several hours before going to bed and by raising the head of the bed or using pillows to raise the head and shoulders.

The stomach produces less acid during pregnancy. Consequently, stomach ulcers rarely develop during pregnancy, and those that already exist often start to heal.

As pregnancy progresses, pressure from the enlarging uterus on the rectum and the lower part of the intestine may cause constipation. Constipation may be worsened because the high level of progesterone during pregnancy slows the automatic waves of muscular contractions in the intestine, which normally move food along. Eating a high-fiber diet, drinking plenty of fluids, and exercising regularly can help prevent constipation.

Hemorrhoids, a common problem, may result from the pressure of the enlarging uterus or from constipation. Stool softeners, an anesthetic gel, or warm soaks can be used if hemorrhoids hurt.

Pica, a craving for strange foods or nonfoods (such as starch or clay), may develop. Occasionally, pregnant women, usually those who also have morning sickness, have excess saliva. This symptom may be distressing but is harmless.

Skin: Mask of pregnancy (melasma) is a blotchy, brownish pigment that may appear on the skin of the forehead and cheeks. The skin surrounding the nipples (areolae) may also darken. A dark line commonly appears down the middle of the abdomen. These changes may occur because the placenta produces a hormone that stimulates melanocytes, the cells that make a dark brown skin pigment (melanin).

Pink stretch marks sometimes appear on the abdomen. This change probably results from rapid growth of the uterus and an increase in levels of adrenal hormones.

Small blood vessels may form a red spiderlike pattern on the skin, usually above the waist. These formations are called spider angiomas. Thin-walled, dilated capillaries may become visible, especially in the lower legs.

Hormones: Pregnancy affects virtually all hormones in the body, mostly because of the effects of hormones produced by the placenta. For example, the placenta produces a hormone that stimulates the woman's thyroid gland to become more active and produce larger amounts of thyroid hormones. When the thyroid gland becomes more active, the heart may beat faster, causing the woman to become aware of her heartbeat (have palpitations). Perspiration may increase, mood swings may occur, and the thyroid gland may enlarge. The disorder hyperthyroidism, in which the thyroid gland is truly overactive, develops in fewer than 1% of pregnancies.

Levels of estrogen and progesterone increase early in pregnancy because human chorionic gonadotropin, the main hormone the placenta produces, stimulates the ovaries to continuously produce them. After 9 to 10 weeks of pregnancy, the placenta itself produces large amounts of estrogen and progesterone. Estrogen and progesterone help maintain the pregnancy.

During pregnancy, changes in hormone levels affect how the body handles sugar. Early in pregnancy, the sugar (glucose) level in the blood may decrease slightly. But in the last half of pregnancy, the level may increase. More insulin (which controls the sugar level in the blood) is needed and is produced by the pancreas. Consequently, diabetes, if already present, may worsen during pregnancy. Diabetes can also begin during pregnancy. This disorder is called gestational diabetes).

Joints and Muscles: The joints and ligaments (fibrous cords and cartilage that connect bones) in the woman's pelvis loosen and become more flexible. This change helps make room for the enlarging uterus and prepare the woman for delivery of the baby. As a result, the woman's posture changes somewhat.

Backache in varying degrees is common, because the spine curves more to balance the weight of the enlarging uterus. Avoiding heavy lifting, bending the knees (not the waist) to pick things up, and maintaining good posture can help. Wearing flat shoes with good support or a lightweight maternity girdle may reduce strain on the back.

Stages of Pregnancy Although pregnancy involves a continuous process, it is divided into three 3-month periods called trimesters (weeks 0 to 12, 13 to 24, and 25 to delivery). EVENTS WEEKS OF PREGNANCY   1st Trimester   The woman's last period before fertilization occurs. 0 Fertilization occurs. The fertilized egg (zygote) develops into a hollow ball of cells called the blastocyst. 2 The blastocyst implants in the wall of uterus. The amniotic sac forms. 3 The area that will become the brain and spinal cord (neural tube) begins to develop. 5 The heart and major blood vessels are developing. The beating heart can be seen during ultrasonography. 6 The beginnings of arms and legs appear. 7 Bones and muscles form. The face and neck develop. Most organs are formed. Brain waves can be detected. The skeleton is formed. Fingers and toes are fully defined. 9 The kidneys begin to function. The fetus can move and respond to touch (when prodded through the woman's abdomen). The woman has gained some weight, and her abdomen may be slightly enlarged. 10 2nd Trimester   The fetus's sex can be identified. The fetus can hear. 14 The fetus's fingers can grasp. The fetus moves more vigorously, so that the mother can feel it. The fetus's body begins to fill out as fat is deposited beneath the skin. Hair appears on the head and skin. Eyebrows and eyelashes are present. The placenta is fully formed. 16 The fetus has a chance of survival outside the uterus. The woman begins to gain weight more rapidly. 23-24 3rd Trimester   The fetus is active, changing positions often. The lungs continue to mature. The fetus's head moves into position for delivery. On average, the fetus is about 20 inches long and weighs about 7 pounds. The woman's enlarged abdomen causes the navel to bulge. 25 DELIVERY 37-42

Sexually Transmitted Diseases

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2). Most genital herpes is caused by HSV-2. Most individuals have no or only minimal signs or symptoms from HSV-1 or HSV-2 infection. When signs do occur, they typically appear as one or more blisters on or around the genitals or rectum. The blisters break, leaving tender ulcers (sores) that may take two to four weeks to heal the first time they occur. Typically, another outbreak can appear weeks or months after the first, but it almost always is less severe and shorter than the first outbreak. Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over a period of years.

Genital herpes?

Results of a nationally representative study show that genital herpes infection is common in the United States. Nationwide, at least 45 million people ages 12 and older, or one out of five adolescents and adults, have had genital HSV infection. Between the late 1970s and the early 1990s, the number of Americans with genital herpes infection increased 30 percent.

Genital HSV-2 infection is more common in women (approximately one out of four women) than in men (almost one out of five). This may be due to male-to-female transmissions being more likely than female-to-male transmission.

HSV-1 and HSV-2 can be found in and released from the sores that the viruses cause, but they also are released between outbreaks from skin that does not appear to be broken or to have a sore. Generally, a person can only get HSV-2 infection during sexual contact with someone who has a genital HSV-2 infection. Transmission can occur from an infected partner who does not have a visible sore and may not know that he or she is infected.

HSV-1 can cause genital herpes, but it more commonly causes infections of the mouth and lips, so-called "fever blisters." HSV-1 infection of the genitals can be caused by oral-genital or genital-genital contact with a person who has HSV-1 infection. Genital HSV-1 outbreaks recur less regularly than genital HSV-2 outbreaks.

What are the signs and symptoms of genital herpes?

Most people infected with HSV-2 are not aware of their infection. However, if signs and symptoms occur during the first outbreak, they can be quite pronounced. The first outbreak usually occurs within two weeks after the virus is transmitted, and the sores typically heal within two to four weeks. Other signs and symptoms during the primary episode may include a second crop of sores, and flu-like symptoms, including fever and swollen glands. However, most individuals with HSV-2 infection may never have sores, or they may have very mild signs that they do not even notice or that they mistake for insect bites or another skin condition.

Most people diagnosed with a first episode of genital herpes can expect to have several (typically four or five) outbreaks (symptomatic recurrences) within a year. Over time these recurrences usually decrease in frequency.

What are the complications of genital herpes?

Genital herpes can cause recurrent painful genital sores in many adults, and herpes infection can be severe in people with suppressed immune systems. Regardless of severity of symptoms, genital herpes frequently causes psychological distress in people who know they are infected.

In addition, genital HSV can cause potentially fatal infections in babies. It is important that women avoid contracting herpes during pregnancy because a first episode during pregnancy causes a greater risk of transmission to the baby. If a woman has active genital herpes at delivery, a cesarean delivery is usually performed. Fortunately, infection of a baby from a woman with herpes infection is rare.

Herpes may play a role in the spread of HIV, the virus that causes AIDS. Herpes can make people more susceptible to HIV infection, and it can make HIV-infected individuals more infectious.

How is genital herpes diagnosed?

The signs and symptoms associated with HSV-2 can vary greatly. Health care providers can diagnose genital herpes by visual inspection if the outbreak is typical, and by taking a sample from the sore(s) and testing it in a laboratory. HSV infections can be difficult to diagnose between outbreaks. Blood tests, which detect HSV-1 or HSV-2 infection, may be helpful, although the results are not always clear-cut.

Is there a treatment for herpes?

There is no treatment that can cure herpes, but antiviral medications can shorten and prevent outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy for symptomatic herpes can reduce transmission to partners.

How can herpes be prevented?

The surest way to avoid transmission of sexually transmitted diseases, including genital herpes, is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Genital ulcer diseases can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of genital herpes only when the infected area or site of potential exposure is protected. Since a condom may not cover all infected areas, even correct and consistent use of latex condoms cannot guarantee protection from genital herpes.

Persons with herpes should abstain from sexual activity with uninfected partners when lesions or other symptoms of herpes are present. It is important to know that even if a person does not have any symptoms he or she can still infect sex partners. Sex partners of infected persons should be advised that they may become infected. Sex partners can seek testing to determine if they are infected with HSV. A positive HSV-2 blood test most likely indicates a genital herpes infection.

Syphilis

Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. It has often been called “the great imitator” because so many of the signs and symptoms are indistinguishable from those of other diseases.

How common is syphilis?

In the United States, health officials reported over 32,000 cases of syphilis in 2002, including 6,862 cases of primary and secondary (P&S) syphilis. In 2002, half of all P&S syphilis cases were reported from 16 counties and 1 city; and most P&S syphilis cases occurred in persons 20 to 39 years of age. The incidence of infectious syphilis was highest in women 20 to 24 years of age and in men 35 to 39 years of age. Reported cases of congenital syphilis in newborns decreased from 2001 to 2002, with 492 new cases reported in 2001 compared to 412 cases in 2002.

Between 2001 and 2002, the number of reported P & S syphilis cases increased 12.4 percent. Rates in women continued to decrease, and overall, the rate in men was 3.5 times that in women. This, in conjunction with reports of syphilis outbreaks in men who have sex with men (MSM), suggests that rates of syphilis in MSM are increasing.

How do people get syphilis?

Syphilis is passed from person to person through direct contact with a syphilis sore. Sores occur mainly on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in the mouth. Transmission of the organism occurs during vaginal, anal, or oral sex. Pregnant women with the disease can pass it to the babies they are carrying. Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils.

What are the signs and symptoms in adults?

Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated. Although transmission appears to occur from persons with sores who are in the primary or secondary stage, many of these sores are unrecognized. Thus, most transmission is from persons who are unaware of their infection.

Primary Stage

The primary stage of syphilis is usually marked by the appearance of a single sore (called a chancre), but there may be multiple sores. The time between infection with syphilis and the start of the first symptom can range from 10 to 90 days (average 21 days). The chancre is usually firm, round, small, and painless. It appears at the spot where syphilis entered the body. The chancre lasts 3 to 6 weeks, and it heals without treatment. However, if adequate treatment is not administered, the infection progresses to the secondary stage.

Secondary Stage

Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically starts with the development of a rash on one or more areas of the body. The rash usually does not cause itching. Rashes associated with secondary syphilis can appear as the chancre is healing or several weeks after the chancre has healed. The characteristic rash of secondary syphilis may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. However, rashes with a different appearance may occur on other parts of the body, sometimes resembling rashes caused by other diseases. Sometimes rashes associated with secondary syphilis are so faint that they are not noticed. In addition to rashes, symptoms of secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The signs and symptoms of secondary syphilis will resolve with or without treatment, but without treatment, the infection will progress to the latent and late stages of disease.

Late Stage

The latent (hidden) stage of syphilis begins when secondary symptoms disappear. Without treatment, the infected person will continue to have syphilis even though there are no signs or symptoms; infection remains in the body. In the late stages of syphilis, it may subsequently damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. This internal damage may show up many years later. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause death.

How does syphilis affect a pregnant woman and here baby?

The syphilis bacterium can infect the baby of a woman during her pregnancy. Depending on how long a pregnant woman has been infected, she may have a high risk of having a stillbirth (a baby born dead) or of giving birth to a baby who dies shortly after birth. An infected baby may be born without signs or symptoms of disease. However, if not treated immediately, the baby may develop serious problems within a few weeks. Untreated babies may become developmentally delayed, have seizures, or die.

How is syphilis diagnosed?

Some health care providers can diagnose syphilis by examining material from a chancre (infectious sore) using a special microscope called a dark-field microscope. If syphilis bacteria are present in the sore, they will show up when observed through the microscope.

A blood test is another way to determine whether someone has syphilis. Shortly after infection occurs, the body produces syphilis antibodies that can be detected by an accurate, safe, and inexpensive blood test. A low level of antibodies will stay in the blood for months or years even after the disease has been successfully treated. Because untreated syphilis in a pregnant woman can infect and possibly kill her developing baby, every pregnant woman should have a blood test for syphilis.

What is the link between syphilis and HIV?

Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection sexually. There is an estimated 2- to 5-fold increased risk of acquiring HIV infection when syphilis is present.

Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by syphilis can bleed easily, and when they come into contact with oral and rectal mucosa during sex, increase the infectiousness of and susceptibility to HIV. Having other STDs is also an important predictor for becoming HIV infected because STDs are a marker for behaviors associated with HIV transmission.

What is the treatment for syphilis?

Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are needed to treat someone who has had syphilis for longer than a year. For people who are allergic to penicillin, other antibiotics are available to treat syphilis. There are no home remedies or over-the-counter drugs that will cure syphilis. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.

Because effective treatment is available, it is important that persons be screened for syphilis on an on-going basis if their sexual behaviors put them at risk for STDs. Persons who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed. Persons with syphilis must notify their sex partners so that they also can be tested and receive treatment if necessary.

Will syphilis recur?

Having syphilis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection. Only laboratory tests can confirm whether someone has syphilis. Because syphilis sores can be hidden in the vagina, rectum, or mouth, it may not be obvious that a sex partner has syphilis. Talking with a health care provider will help to determine the need to be re-tested for syphilis after treatment has been received.

How can syphilis be prevented?

The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Avoiding alcohol and drug use may also help prevent transmission of syphilis because these activities may lead to risky sexual behavior. It is important that sex partners talk to each other about their HIV status and history of other STDs so that preventive action can be taken.

Genital ulcer diseases, like syphilis, can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of syphilis, as well as genital herpes and chancroid, only when the infected area or site of potential exposure is protected.

Condoms lubricated with spermicides (especially Nonoxynol-9 or N-9) are no more effective than other lubricated condoms in protecting against the transmission of STDs. Based on findings from several research studies, N-9 may itself cause genital lesions, providing a point of entry for HIV and other STDs. In June 2001, the CDC recommended that N-9 not be used as a microbicide or lubricant during anal intercourse. Transmission of a STD, including syphilis cannot be prevented by washing the genitals, urinating, and or douching after sex. Any unusual discharge, sore, or rash, particularly in the groin area, should be a signal to refrain from having sex and to see a doctor immediately.

Gonorrhea

Gonorrhea is a sexually transmitted disease (STD). Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract, including the cervix (opening to the womb), uterus (womb), and fallopian tubes (egg canals) in women, and in the urethra (urine canal) in women and men. The bacterium can also grow in the mouth, throat, eyes, and anus.

How common is gonorrhea?

Gonorrhea is a very common infectious disease. CDC estimates that more than 700,000 persons in the U.S. get new gonorrheal infections each year. Only about half of these infections are reported to CDC. In 2004, 330,132 cases of gonorrhea were reported to CDC. In the period from 1975 to 1997, the national gonorrhea rate declined, following the implementation of the national gonorrhea control program in the mid-1970s. After a small increase in 1998, the gonorrhea rate has decreased slightly since 1999. In 2004, the rate of reported gonorrheal infections was 113.5 per 100,000 persons.

How do people get gonorrhea?

Gonorrhea is spread through contact with the penis, vagina, mouth, or anus. Ejaculation does not have to occur for gonorrhea to be transmitted or acquired. Gonorrhea can also be spread from mother to baby during delivery.People who have had gonorrhea and received treatment may get infected again if they have sexual contact with a person infected with gonorrhea.

Who is at risk for gonorrhea?

Any sexually active person can be infected with gonorrhea. In the United States, the highest reported rates of infection are among sexually active teenagers, young adults, and African Americans.

What are the signs and symptoms of gonorrhea?

Although many men with gonorrhea may have no symptoms at all, some men have some signs or symptoms that appear two to five days after infection; symptoms can take as long as 30 days to appear. Symptoms and signs include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. Sometimes men with gonorrhea get painful or swollen testicles.

In women, the symptoms of gonorrhea are often mild, but most women who are infected have no symptoms. Even when a woman has symptoms, they can be so non-specific as to be mistaken for a bladder or vaginal infection. The initial symptoms and signs in women include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods. Women with gonorrhea are at risk of developing serious complications from the infection, regardless of the presence or severity of symptoms.

Symptoms of rectal infection in both men and women may include discharge, anal itching, soreness, bleeding, or painful bowel movements. Rectal infection also may cause no symptoms. Infections in the throat may cause a sore throat but usually causes no symptoms.

What are the complications of gonorrhea?

Untreated gonorrhea can cause serious and permanent health problems in both women and men.
In women, gonorrhea is a common cause of pelvic inflammatory disease (PID). About one million women each year in the United States develop PID. Women with PID do not necessarily have symptoms. When symptoms are present, they can be very severe and can include abdominal pain and fever. PID can lead to internal abscesses (pus-filled “pockets” that are hard to cure) and long-lasting, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube.

In men, gonorrhea can cause epididymitis, a painful condition of the testicles that can lead to infertility if left untreated. Gonorrhea can spread to the blood or joints. This condition can be life threatening. In addition, people with gonorrhea can more easily contract HIV, the virus that causes AIDS. HIV-infected people with gonorrhea are more likely to transmit HIV to someone else.

If a pregnant woman has gonorrhea, she may give the infection to her baby as the baby passes through the birth canal during delivery. This can cause blindness, joint infection, or a life-threatening blood infection in the baby. Treatment of gonorrhea as soon as it is detected in pregnant women will reduce the risk of these complications. Pregnant women should consult a health care provider for appropriate examination, testing, and treatment, as necessary.

Several laboratory tests are available to diagnose gonorrhea. A doctor or nurse can obtain a sample for testing from the parts of the body likely to be infected (cervix, urethra, rectum, or throat) and send the sample to a laboratory for analysis. Gonorrhea that is present in the cervix or urethra can be diagnosed in a laboratory by testing a urine sample. A quick laboratory test for gonorrhea that can be done in some clinics or doctor's offices is a Gram stain. A Gram stain of a sample from a urethra or a cervix allows the doctor to see the gonorrhea bacterium under a microscope. This test works better for men than for women.

Several antibiotics can successfully cure gonorrhea in adolescents and adults. However, drug-resistant strains of gonorrhea are increasing in many areas of the world, including the United States, and successful treatment of gonorrhea is becoming more difficult. Because many people with gonorrhea also have chlamydia, another sexually transmitted disease, antibiotics for both infections are usually given together. Persons with gonorrhea should be tested for other STDs.

It is important to take all of the medication prescribed to cure gonorrhea. Although medication will stop the infection, it will not repair any permanent damage done by the disease. People who have had gonorrhea and have been treated can get the disease again if they have sexual contact with persons infected with gonorrhea. If a person's symptoms continue even after receiving treatment, he or she should return to a doctor to be reevaluated.

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex condoms, when used consistently and correctly, can reduce the risk of transmission of gonorrhea.
Any genital symptoms such as discharge or burning during urination or unusual sore or rash should be a signal to stop having sex and to see a doctor immediately. If a person has been diagnosed and treated for gonorrhea, he or she should notify all recent sex partners so they can see a health care provider and be treated. This will reduce the risk that the sex partners will develop serious complications from gonorrhea and will also reduce the person's risk of becoming re-infected. The person and all of his or her sex partners must avoid sex until they have completed their treatment for gonorrhea.

Chlamydia

Chlamydia is a common sexually transmitted disease (STD) caused by the bacterium, Chlamydia trachomatis, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. Chlamydia also can cause discharge from the penis of an infected man.

Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. In 2004, 929,462 chlamydial infections were reported to CDC from 50 states and the District of Columbia. Under-reporting is substantial because most people with chlamydia are not aware of their infections and do not seek testing. Also, testing is not often done if patients are treated for their symptoms. An estimated 2.8 million Americans are infected with chlamydia each year. Women are frequently re-infected if their sex partners are not treated.

Chlamydia can be transmitted during vaginal, anal, or oral sex. Chlamydia can also be passed from an infected mother to her baby during vaginal childbirth. Any sexually active person can be infected with chlamydia. The greater the number of sex partners, the greater the risk of infection. Because the cervix (opening to the uterus) of teenage girls and young women is not fully matured, they are at particularly high risk for infection if sexually active. Since chlamydia can be transmitted by oral or anal sex, men who have sex with men are also at risk for chlamydial infection.

Chlamydia is known as a "silent" disease because about three quarters of infected women and about half of infected men have no symptoms. If symptoms do occur, they usually appear within 1 to 3 weeks after exposure.

In women, the bacteria initially infect the cervix and the urethra (urine canal). Women who have symptoms might have an abnormal vaginal discharge or a burning sensation when urinating. When the infection spreads from the cervix to the fallopian tubes (tubes that carry eggs from the ovaries to the uterus), some women still have no signs or symptoms; others have lower abdominal pain, low back pain, nausea, fever, pain during intercourse, or bleeding between menstrual periods. Chlamydial infection of the cervix can spread to the rectum.

Men with signs or symptoms might have a discharge from their penis or a burning sensation when urinating. Men might also have burning and itching around the opening of the penis. Pain and swelling in the testicles are uncommon. Men or women who have receptive anal intercourse may acquire chlamydial infection in the rectum, which can cause rectal pain, discharge, or bleeding. Chlamydia can also be found in the throats of