Taking Charge of Your Fertility

by Toni Weschler

  Luteal Phase Insufficiency

  If you are trying to conceive and have what is referred to as postmenstrual brown or black bleeding (defined as two or more days of spotting at the tail end of your period), it’s probably caused by an irregular shedding of the endometrium and small fragments of endometrial tissue. This is usually the result of suboptimal luteal function in the prior cycle.

  Likewise, if you are trying to get pregnant and you often have two or more days of brown or black bleeding leading up to menstruation, you could theoretically be at risk for a potential miscarriage. This is because, in order for implantation to occur, the uterine lining must be sufficient for the egg to burrow into before it is shed during menstruation. Both of these are usually treated by focusing on supporting your luteal phase or treating ovulation itself.

  Pelvic Inflammatory Disease (PID) or STIs

  You should be especially alert to such signs as cramping or abdominal pain, abnormal vaginal discharge, fevers and chills, or any kind of pain during urination or intercourse. Such symptoms, when accompanied by unusual bleeding, could be characteristic of a variety of conditions, from pelvic infections to various sexually transmitted infections.

  Endometriosis and Other Disorders

  Another possible cause of premenstrual spotting is endometriosis, which can also cause heavy menstrual bleeding or irregular bleeding between periods. If you note other unexplainable bleeding, you should consider getting a diagnosis because it could be caused by hormonal imbalances such as thyroid problems, excess estrogen, or Polycystic Ovarian Syndrome, to name just a few. Fortunately (or not!), most cases of unusual bleeding caused by these conditions are accompanied by other symptoms, so it should make them a little easier to diagnose.

  Fibroids

  Although clots are often normal during menstruation, they could reflect potential fibroids if you start getting them when they’ve never occurred before. If they seem excessive or annoying and you would prefer to treat them, discuss this with your doctor. And if you think you might be pregnant and pass large clots along with gray tissue, contact your physician immediately, because you could be having a miscarriage. (Click here to see the page in the color insert for more on fibroids.)

  Dysfunctional Uterine Bleeding (DUB)

  The most common type of unusual bleeding has no obvious organic or structural origin. It is often referred to as dysfunctional uterine bleeding (or DUB), and it’s usually diagnosed as such when all organic causes have been eliminated. DUB is usually assumed to have a hormonal basis, with about 90% due to anovulation. It typically occurs in women with long or irregular cycles, such as those with PCOS. It also often occurs in those who are at the two extremes of reproductive age, either early puberty or perimenopause.

  Because there are so many potential causes of unusual bleeding, I’ve included a more comprehensive summary of the most common ones in the table below. Note that the bleeding issues are in the approximate order that they appear in the cycle, beginning with the menstrual period itself.

  Of course, being able to share your chart with your physician will allow her to see when the bleeding is occurring and what the quality of the flow is, making it that much easier to diagnose.

  CAUSES OF UNUSUAL BLEEDING DURING DIFFERENT PHASES OF THE CYCLE

  HEAVY BLEEDING DURING PERIOD

  Soaking through a sanitary pad or tampon every one to two hours for at least several consecutive hours.

  Submucous uterine fibroids Benign growths that bulge into the uterine cavity and are located just under the lining of the uterus. They tend to bleed more heavily than other types of fibroids, and are more difficult to treat (see types of uterine fibroids here in the color insert).

  Endometriosis The condition in which some of the uterine cells that normally shed during menstruation attach themselves elsewhere in the body, most often within the pelvic cavity.

  Endometrial hyperplasia (adenocarcinoma) An overgrowth of the glandular components of the uterine lining. It can be precancerous.

  Cystic hyperplasia An overgrowth of fluid-filled cysts in the uterine lining.

  Adenomyosis A condition in which the endometrial tissue, which normally lines the uterus, penetrates its muscular walls instead, potentially causing severe menstrual cramps and heavy periods.

  Coagulation disorders Conditions such as systemic lupus, in which the body is not able to control blood clotting effectively.

  TAIL-END PERIOD SPOTTING

  Two or more days of brown or black spotting that occurs at the tail end of your period.

  Endometritis An infection or inflammation of the cells lining the uterus, which can occasionally be chronic.

  PROLONGED POSTMENSTRUAL BROWN BLEEDING

  Brown or black spotting that continues for days beyond the red bleeding of menstruation.

  Corpus luteum deficiency 3 days or more of dark spotting.

  Endometrial hyperplasia (adenocarcinoma) An overgrowth of the glandular components of the uterine lining. It can be precancerous.

  Cystic hyperplasia An overgrowth of fluid-filled cysts in the uterine lining.

  Adenomyosis A condition in which the endometrial tissue that normally lines the uterus penetrates its muscular walls instead, causing potentially painful and heavy periods.

  BLEEDING EARLY IN CERVICAL FLUID BUILDUP

  Endometrial polyps A piece of tissue that projects into the uterine cavity through a large base or thin stalk that attaches to the uterine lining.

  Endometrial hyperplasia (adenocarcinoma) An overgrowth of the glandular components of the uterine lining. It can be precancerous.

  OVULATORY BLEEDING

  This is normal but included because the technical definition of unusual bleeding is any bleeding that is not a menstrual period.

  Estrogen breakthrough Spotting that occurs just before the Peak Day, and is the result of excess estrogen stimulating the endometrium.

  Estrogen withdrawal Spotting that occurs within the 3 days immediately following the Peak, and is the result of the sudden drop in estrogen just before ovulation.

  PROLONGED PREMENSTRUAL BLEEDING (LUTEAL PHASE)

  Endometritis An infection or inflammation of the cells lining the uterus.

  Submucous fibroids Benign growths that bulge into the uterine cavity and are located just under the lining of the uterus. They tend to bleed more heavily than other types of fibroids, and are more difficult to treat (see types of uterine fibroids here in the color insert).

  Endometrial polyps A piece of tissue that projects into the uterine cavity through a large base or thin stalk that attaches to the uterine lining.

  PREMENSTRUAL SPOTTING (LUTEAL PHASE)

  3 or more days of light or brown spotting that occurs prior to the first day of red menstrual bleeding.

  Low progesterone Not enough progesterone to maintain the uterine lining, which leads to the premature breakdown of endometrial capillaries.

  Endometriosis The condition in which some of the uterine cells that normally shed during menstruation attach themselves elsewhere in the body, most often within the pelvic cavity.

  ANOVULATORY BLEEDING

  These may occur after menopause, as well.

  Estrogen breakthrough Light or brown spotting or heavy and prolonged bleeding that is the result of excess estrogen stimulating the endometrium without progesterone from ovulation to sustain it. This is especially characteristic of women with PCOS.

  Estrogen withdrawal Bleeding that can be anything from heavy with clots to just spotting. It is the result of the follicle maturing enough to release estrogen that thickens the endometrial lining before the follicle breaks down. This causes the estrogen to drop and bleeding to occur.

  Endometrial polyps A piece of tissue that projects into the uterine cavity through a large base or thin stalk that attaches to the uterine lining.

  Endometrial hyperplasia (adenocarcinoma) An overgrowth of the glandular components of the uterine lining. It can be precancerous.

  Organic Causes
of Unusual Bleeding

  This is bleeding that emanates from an anatomic or structural problem of the uterus, as opposed to a hormonal imbalance, and can occur at any time in your cycle. Some of these conditions were noted in the previous table, but they are listed here again, for clarity.

  Endometrial polyps A piece of tissue that projects into the uterine cavity through a large base or thin stalk that attaches to the uterine lining. It is usually benign.

  Endometrial hyperplasia (adenocarcinoma) An overgrowth of the glandular components of the uterine lining. It can be precancerous.

  Endometritis An infection or inflammation of the cells lining the uterus.

  Pelvic Inflammatory Disease (PID) Pelvic infections that can cause irregular bleeding along with a host of other symptoms discussed here. It should be treated immediately to prevent scarring that could lead to infertility.

  Chronic cervicitis A chronic inflammation of the cervix usually due to either cervical eversion, an infection, injury of the cervix, or rarely, cancer. It can be triggered by an STI, but may also have noninfectious causes.

  Acute cervicitis that is not treated develops into chronic cervicitis, which can lead to an excessive vaginal discharge, bleeding between periods, and spotting after sex.

  Fibroids Benign tumors that are located in various parts of the uterus. They can grow to be very large, and both the size and location of the fibroids affect the severity of the bleeding they may cause.

  Thyroid Dysfunction A condition in which a woman may experience unusual bleeding, in addition to numerous other symptoms, as discussed here.

  Adenomyosis A condition in which the endometrial tissue, which normally lines the uterus, penetrates its muscular walls instead. It can cause potentially painful and heavy periods.

  Click here for more on unusual bleeding while charting.

  CHAPTER 20

  Appreciating Your Sexuality and Nurturing Your Relationship

  “How is your sex life? How often do you have sex?” asked their respective therapists. Alvy Singer reflected. “Hardly ever, maybe three times a week,” he whined. “Constantly . . . I’d say three times a week!” Annie Hall complained. He felt deprived. She felt exhausted.

  —SCENE FROM WOODY ALLEN’S ANNIE HALL (1977)

  Does that sound familiar? A woman’s sexuality doesn’t have to be the mystery so many people think it is. In reality, there are a number of ways in which women and men differ sexually.

  Many women tend to view lovemaking as an emotional and intimate experience, not just a physical act. So women may tend to get aroused if they feel trust and affection in the hours and even days leading up to intercourse. Many men, on the other hand, tend to place more importance on the visual and other stimuli at the actual time of sexual interaction.

  In addition, a woman’s physical experience of sex is quite different from a man’s simply because her clitoris is located outside of her vagina. This one fact can dramatically affect every aspect of her emotional and physical sexuality.

  My friend Bill explained it best when he casually mentioned over lunch one day that girls have it easy:

  “When they are 16 or 17 years old and with their boyfriend, they reach down and touch him and Boom! Ahhh, so that’s what it takes. She’s got it figured out. The guy, on the other hand, experiences his whole life with women as stepping into the cockpit of a 747: I know there’s a button somewhere that turns this thing on.”

  Alas, a woman’s sexuality is also often closely tied to her cycle, as well. Many women themselves don’t understand this. Is it any wonder, then, that men often find women somewhat confusing? But men who help their partners chart often maintain that they finally get female sexuality in a way that often eluded them before. They describe the newfound wisdom that they’ve acquired in understanding an aspect of women that is so frequently misunderstood. These next few pages will hopefully clarify the puzzle and make you appreciate the secret of your sexuality.

  What You’ve Been Missing: For the 10 to 15% of Women Who’ve Never Had an Orgasm

  Not only have scores of women never climaxed, but only about 25% can experience orgasms through intercourse alone. Of course, you can’t expect a man to know how to give you one if you, yourself, don’t know what works for you. So, if you’ve never had one, this handy little list below is for you. Enjoy the research.

  Shower or bath streams

  One of the best and least-intimidating ways for women to learn how to have an orgasm is to light a candle and lie comfortably in the bath or shower with a bath pillow under their head, letting a warm stream of water flow over their clitoris. If you can find the right time and privacy, it’s one of the most relaxing and sensual ways to experience your first of hopefully many climaxes.

  Copyright © 1988, Los Angeles Times Syndicate, reprinted by permission.

  Vibrators

  You’ve undoubtedly heard references to women’s love affair with vibrators, and for good reason. While men can practically have an orgasm just by looking at a female body, for women it’s a tad more challenging. Regardless, the most fail-proof way for women to have an orgasm is with a vibrator, provided they determine which kind is right for them. In fact, there are dozens of different types.

  There are phallic-shaped vibrators that obviously mimic an erect penis, designed to be inserted. There are curved ones designed to reach the G-spot (more on that below). There are those used only on the clitoris itself, and there are tiny discreet ones designed to be used on the clitoris specifically during intercourse. Finally, there are ingeniously designed ones that are phallic-shaped and have an accessory attached to the outside, made to simultaneously stimulate the clitoris while it is inside the vagina—a twofer, if you will.

  The best way to learn what works for you is to visit one of the numerous women-centered sex toy boutiques that have popped up throughout most big cities. Gone are the days of seedy, back-alley sex shops frequented only by suspicious-looking men. Now, women and couples can explore all manner of sex toys and attend enlightening classes on every facet of human sexuality, including, of course, how to have an orgasm (yep, there are classes on how to have an orgasm).

  Texting as foreplay

  Who would have predicted that with the advent of smartphones, the sex lives of men and women everywhere could be so enhanced? Enter texting and its ability to create a slow simmer throughout the day, so that by the time you and your partner finally see each other that evening, you’re ready to tear each other’s clothes off.

  Erotic imagery

  There probably isn’t a woman in America who hasn’t heard of the book Fifty Shades of Grey. Its popularity is a testament to the ability of erotic books and videos to arouse not just men, but women as well. Indeed, there are entire genres of adult videos made specifically for couples, and for many of them, there is nothing sexier than sitting in the privacy of their own home, watching erotica as a way to get their juices flowing.

  Extensive teasing and withholding

  When it comes to helping women climax, sometimes the simplest things are overlooked. For many of you, perhaps the easiest and sexiest thing your partner can do for you is to intentionally withhold caressing your vaginal area while focusing everywhere else, so that you practically have to plead with him to finally let you climax.

  Stimulation of the elusive G-spot

  And then, of course, there is the ever-mysterious G-spot—undoubtedly still the most hotly debated topic in the field of human sexuality today. Does it or doesn’t it exist? And if it does exist, where the hell is it anyway? When I initially started researching the first edition of this book back in the early 1990s, the G-spot was so poorly understood that I chose not to include anything about it. But I certainly thought that 20 years later, enough scientific studies would have been conducted that we would finally know definitively whether it actually exists!

  Wrong. Part of the confusion stems from the fact that, unlike the clitoris, the G-spot has yet to be scientifically identified as a distinct
structure. Although many women experience intense sexual pleasure and orgasms stemming from the top front of the vagina, nobody has been able to document a more precise source, or describe its size and appearance. Still, for the purposes of this discussion, we’ll assume that there is indeed an entity that some women have, or at least that some women find sensitive, and we’ll refer to it as the G-spot.

  It’s been described as an area of spongy tissue, about the size of a quarter, on the paraurethral gland (the gland beside the urethra), which is analogous to the male prostate. It’s located about an inch or two inside your vagina on the wall that is closest to your belly button. It has a different texture than the rest of your vagina, because it is comprised of erectile tissue with ridges, allowing it to swell when you are sexually aroused. This makes it easier for your partner to find it after extensive foreplay, as seen here in the color insert.

  Because of its location on the upper vaginal wall, it’s hard for a woman herself to be able to reach it effectively. The best way for you to access it is with one of the vibrators specifically designed for that purpose. Of course, your partner can also stimulate it much more easily by inserting his index or middle finger all the way in, then bending it up in a “come hither” motion until he finds the area that is more ridged than the rest of the vaginal wall.

  Given the G-spot’s internal location, he may need to rub harder in order for you to feel it. And, in an interesting twist, older women may find it more arousing because their vaginas tend to be a little thinner, making the G-spot more prominent. Regardless, if you don’t feel anything, you may want him to use his other hand to press on your pubic bone at the same time, which might intensify the physical sensation.

  Men should not be afraid to stop and ask for directions.

  www.CartoonStock.com

  Oral sex (cunnilingus)

  One of the sexiest and most reliable ways a woman can achieve an orgasm is through her partner performing oral sex on her with his warm tongue (of course, neither of you will likely enjoy it unless you are squeaky clean). In addition, it’s vital for your partner to understand how excruciatingly sensitive the clitoris can be if touched directly, whether with his fingers or tongue. And if you don’t feel comfortable telling him to stay clear of your clitoris after you’ve climaxed, your shrieks of pain should be a subtle but effective cue.