History of the IUD

Speaking of Dr. Ernst Gräfenberg, let’s talk about intrauterine devices (IUDs) since Dr. G is recognized as the first developer of the modern IUD.  IUDs, in a crude sense, have existed for an untold number of years.  Women and men have inserted various implements into human and animal uteri to prevent pregnancy for many years.  Forerunners to the modern IUD emerged in the beginning of the twentieth century with inventions such as the stem pessary.

The first true modern IUD was invented in the late 1920s by Dr. Gräfenberg when he was still practicing gynecology in Germany.  The IUD that Dr. G invented was, instead of the familiar t-shaped device, actually a circle-shaped device:  the Gräfenberg ring.  These rings were silk threads covered with fine silver wire.  The metal of this device caused an inflammatory response in the uterus thus creating hostile conditions for sperm.  He later found that some copper mixed with the silver aided in the contraceptive ability of the device.  (Of course, for a number of uteri in which these were inserted the inflammation was so great as to cause complications, though these were rarely severe.)  By the end of the 1930s, the Gräfenberg ring fell out of use mostly because of the eugenic policies implemented by Nazi Germany (in which all contraception was outlawed, as it was in Japan as well).  Gräfenberg himself left Germany in 1937 to escape persecution because of his Jewish heritage.

The modern plastic-based IUD began to take shape in the United States in the 1950s.  Lazar C. Margulies, an obstetrician in New York, is generally credited for pioneering plastic IUDs to help reduce the danger associated with previous IUDs.  In 1958 he introduced his version of the IUD, though it was not greatly successful because of its large size.  In 1962, Jack Lippes, a gynecologist also in New York, developed a smaller, plastic IUD that became more popular.  In the late 1960s, Howard Tatum, another New York obstetrician, developed a plastic-cased, cooper-based IUD that could be dramatically reduced in size without sacrifcing its effectiveness.  During the 1970s, in an effort to help cheaply curb reproduction and enforce the “one-child policy,” Chinese physicians developed the stainless-steel IUD, but banned them by early 1990s because of a 10% pregnancy rate due to steel’s lowered contraceptive capability.

The second generation of plastic-copper IUDs came around in the 1970s.  These IUDs increased the surface area of the devices and increased their effectiveness above 99%.  Today, in the United States, this type of IUD and one other type are available.  The copper IUD available in the United States is called ParaGuard and is effective for twelve years.  The other type of IUD available in the United States is a hormone-based IUD, called Mirena, that functions in a few ways.  This IUD first creates a hostile environment for sperm, much like copper-IUDs by thinning the uterine lining making it highly unlikely a fertilized egg could implant in the uterus.  Second, the hormones involved create a thicker cervical plug making it less likely that sperm will enter the uterus to begin with.  Finally, the hormone-IUD in some instances stops the ovary from releasing an egg, though this is less likely than the other two functions.  Hormone-based IUDs were developed in the 1970s, but have not been popular in the United States until recently because of ad campaigns for Mirena (though they remain relatively very unpopular compared to condoms and the pill).

This is all a sort of background to understanding the IUD.  Hopefully, in a later entry we can better address the scientific and medical aspects of IUDs in their modern form.  Do you have something to say about IUDs?  Or anything else?  I yield the floor.

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The “G Spot”

We mentioned the “g spot” a few entries back and it clearly begged more attention. So, what IS the g spot? Why is it called the g spot? What can the g spot do? What can’t it do? Does everyone have a g spot? Let’s try to get some answers to these questions.

The “g spot” is named after a German-born, American-practicing gynecologist named Ernst Gräfenberg who hypothesized between 1944 and 1950 that such a spot existed. He described it as “an erotic zone [in the vagina] that would swell during sexual stimulation.” The g spot is supposed to be a cluster of nerve endings that lend themselves to a heightened response to stimulation. The g spot is presumed to be located centrally on the front wall of the vagina (directly adjacent to the bladder). Stimulation of the g-spot is purported to intensify orgasms and promote instances of female ejaculation.

Of course, many gynecologists and researchers (and many average women!) argue against the existence of a “g spot.”  Among those who support the idea of a g spot, reasons vary as to its purpose and origin.  Proponents argue that the g spot is describable besides its ability to induce pleasure; it is a small patch (varying in size) that is rough, like a walnut, unlike the rest of the smooth vagina.  One prominent argument for the g spot purports that the tissue that makes up the g spot is the female homologue of the prostate.  This “female prostate,” also called Skene’s gland, is supposedly responsible for female ejaculation.  Another argument maintains that the g spot is simply an extension of the network of nerves extending from the clitoris, being part of the “anterior wall erogenous complex.”  Thus, stimulation of the g spot is just stimulation of the clitoris.  Finally, a third argument suggests that the g spot is actually an evolutionary tool that helps women cope with the pain of childbirth.  Research has shown that stimulation of the g spot increases pain tolerance by 47%.  This amount goes up when aroused and more than doubles during orgasm–though the chances of being sexually aroused or orgasm during childbirth are slim to none, I daresay.

So, how many women actually have g spots?  No on really seems to know.  Virtually every study that has been done on the subject has been disputed for some reason or another.  Most studies have been limited to very small numbers of women, thus not giving an accurate cross-section of the general population.  Also, many researchers base their findings on the study of an individual woman, not women.  Thus, g spot studies are usually criticized for relying too heavily on anecdotal evidence.  So while it is unclear what percentage of women have a g spot, it is very clear that not all women have one–even by the “walnut” definition.  Even among women who report having a g spot, not all women report the same benefits.  Indeed, numerous women who say they do have an area of increased sensation on the anterior vaginal wall note that it is unpleasant and that too much stimulation is painful.

The debate over the g spot, or perhaps lack thereof, is not likely to be settled any time soon.  Much more research needs to be done to say anything conclusively about this phenomenon.  So, do you have anything to add or a question to ask?  Go for it.

The Clitoris

So, since I’ve mentioned the clitoris in the several past entries, let’s talk about it a little more. The clitoris is oftentimes the most misunderstood part of women’s genitalia. Men seem to know little about it, and many women don’t know much more about it than men. What is it? What does it do?

The etymology of the word clitoris is uncertain, but may have derived from the Greek kleitoris, meaning “little hill.” The clitoris, sometimes abbreviated as “clit,” is the homologous structure of the penis found in males. (Though, to be more biologically accurate, the penis is the homologous structure to the clitoris in females.) Normally, all female mammals have a clitoris, the spotted hyena possibly have the most interesting clitoris. Not only does the spotted hyena urinate through its clitoris, unlike all other mammals, but it also gives birth through its clitoris.

In humans, the clitoris is usually a small, “button-like” projection in the genitalia that is nestled in the anterior of the labia. Only the tip of the clitoris is visible and the interior shaft can reach up to five inches in depth. Like a penis, a clitoris becomes stiff and swollen when aroused. However, because the urethra is separate from the clitoris and sexual intercourse and childbirth occur through the vagina, the clitoris seems to only function for sexual pleasure. The clitoris has thousands of nerve endings, much more densely clustered than those in the penis.

Masters and Johnson argued in 1966 that clitoral orgasm is the only type of orgasm [169].   After examining vaginas closely, they found that the tissue of the vagina itself was incapable of producing an orgasm. While on the surface, this argument is very easily rebuked, Masters and Johnson had a more complex argument. They argued that clitoral tissues extends throughout the vulva and vagina, thus what is felt to be vaginal stimulation is simply an extended form of clitoral stimulation.  Of course, many people have criticized this argument as it clearly does not address how orgasms can be achieved through stimulation of distant body parts such as the breast.

The clitoris has often been a target of misogynistic fear, as evidenced by some of the motives in female genital modification and mutilation.  Amnesty International estimates there are 6,000 incidences of female genital mutilation every day.  Of course, misogyny is not the only reason for this practice but it is a driving force.  The clitoris is a symbol of evil to various cultures whose beliefs range from babies dying if they come in contact with a clitoris during childbirth to a woman’s sexuality being untamable if she has an intact clitoris.  As it is important in these cultures to ensure the children a man’s wife bears are indeed his children, a clitoridectomy (and other forms of mutilation) is seen as a way of ensuring a woman will remain faithful to her husband.

Of course, there is much more that could be said about the clitoris in general and clitorises in particular, but this is just meant to be a beginning basis of discussion of the clitoris.  So, any question or comments?  I’d love to hear from you!

The First Oophorectomy

Having had an oophorectomy, I am incredibly interested in the surgical removal of ovaries.  Removal of one ovary is called a unilateral oophorectomy; removal of both is bilateral.  Usually, when an ovary is removed, the fallopian tube associated with it is also removed.  This is called a salpingo-oophorectomy.  My interest usually lies in new surgical techniques and the philosophical implications of an oophorectomy.  But, of course, my training in history leads me inevitably to investigating the historical genesis of the oophorectomy.

So, where and when was the first successful oophorectomy performed, you ask?  Actually, it happened just down the road from here in Danville, Kentucky on Christmas Day, 1809.  Who’d have guessed it, right?  Actually, this is not the most talked about first in medical history so it could have easily passed me by had I not spent a summer in Danville five years ago.  There is a statue to the surgeon who performed the first oophorectomy (referred to then as an ovariotomy) alongside his interred remains in a park very near Centre College in Danville.

Ephraim McDowell, the surgeon in question, was a sparsely trained country surgeon in Kentucky between 1795 and 1830.  He studied medicine at various places in Virginia and Scotland, though never attained a degree.  (He was later granted an honorary M. D. in 1825 from the University of Maryland.)  He married Sarah Shelby, the daughter of the first Governor of Kentucky Isaac Shelby.  McDowell’s practice was nothing out of the ordinary until December 13, 1809 when he was summoned to attend to a woman in Green County, Kentucky about 60 miles away.

This woman, Jane Todd Crawford, 46, was believed to be pregnant past term.  Upon examination, McDowell diagnosed a very large ovarian tumor.  He explained to Crawford the dangers of both leaving the tumor untreated and of operating on the tumor.  No such operation had been performed successfully before, so she would almost certainly die as a result, though she was likely to die quickly otherwise.  She decided to move forward with the surgery.  She arrived at McDowell’s house on Christmas as prescribed to undergo the operation.

McDowell began the surgery without the aid of anesthetics or antiseptics.  The procedure took 25 minutes.  He removed a cystic mass, partially solid and partially liquid, weighing 22.5 pounds.  Crawford not only recovered, but lived for thirty-two more years.  McDowell did not write up the notes on this case until seven years afterward in which time he performed several more abdominal surgeries successfully.  When he did write up his notes, he mentioned that when visiting Crawford in her room five days following the surgery he found her making her bed.  (Having undergone the same procedure with modern benefits and a tumor only half that size, I can tell you that is nothing short of miraculous.)

The reasons McDowell and subsequent scholars have pointed to as the reasons why his surgical techniques are several in number.  First of all, McDowell carefully cleansed every surface he touched including bathing Crawford’s intestines before replacing them in the abdomen.  Also, McDowell removed the blood that collected in Crawford’s open abdomen before suturing the incision.  Blood left in the body following surgery accounted for a great number of illnesses and deaths during that time.  Another step taken by McDowell to ensure success was placing a ligature at the base of the affected fallopian tube where it met the uterus.  This ensured that blood would not continue to flow to the ovary and tumor during the operation.  Furthermore, McDowell closed the abdomen with large interrupted sutures including adhesive to promote the apposition of skin.

McDowell’s innovations and sheer daring culminated in an achievement that is often referred to as the founding of abdominal surgery.  There is some debate over whether he was the first to perform an “ovariotomy,” though it seems clear to me he was.  It is a stretch to say he was the first to successfully perform an abdominal surgery, especially considering the first recorded, mutually-successful cesarean section was performed in 1500 in Switzerland.  In any event, McDowell’s techniques were pioneering and generally successful.  Modern procedures still closely resemble what McDowell did in 1809.  Questions?  Comments?  Go for it.

Female Orgasm and Resolution

By popular demand (or at least one demand), today’s entry will make a complete circle of Masters and Johnson’s human sexual response cycle.  So, what happens after arousal?  For women (and sometimes men), arousal does not always result in the obvious:  orgasm.  Many women have trouble reaching orgasm, while many others reach multiple orgasms.  These are variants of the M & J sexual response cycle, but we’ll get to that.

So what happens during a woman’s orgasm?  Following the changes that occur during the excitement and plateau phases (arousal), several other physiological changes occur.  For instance, when a woman nears orgasm the glans in the clitoris moves inward under the clitoral hood and the labia minora darken.   The vagina tightens, then lengthens and dilates while becoming more engorged.  The muscles of the uterus then begin to rhythmically contract.  Dutch researchers found earlier this year that it is possible to objectively determine orgasms in women by measuring the frequencies of contractions in the uterus, vagina, anus, and pelvic muscles.  It is not uncommon, however, for other muscles to contract and spasm.  The well-known toes poking out from the sheets is probably the most commonly cited “non-sexual” muscle contraction during orgasm.

Women have a more difficult time reaching orgasm than men and can often go through only the first two stages of sexual response, but still feel they had a satisfactory sexual experience.  To make up for the greater difficulty of achieving orgasm, women do have a few checks in their column.  Women usually have longer orgasms than men.  Men’s are usually only a few seconds long.  Women are also able to achieve much hyped “multiple orgasms” (note that, oddly, about 5/6ths of the “multiple orgasms” section of this article is devoted to males).   This means that a woman can achieve the third stage of sexual response multiple times without necessarily having to go through the fourth and first stages again–the woman simply reverts to the second stage, then returning to the third stage again.

Following orgasm, the woman enters into the fourth and final stage of the human sexual response cycle:  the resolution (sometimes referred to as the refractory period).  During this phase, the body returns to its original, pre-arousal state.  Some of the changes required to return to normal take place right away, while others take longer.  Technically speaking, women do not have a refractory period and men do.  The refractory period is the time frame within the resolution after which the sexual response cycle can begin again.  The refractory period can be anywhere from a few minutes to a few days depending on the health and age of the man.  Women do not have a refractory period because their bodies, generally speaking, are always ready to reenter the sexual response cycle (thus the ability to achieve multiple orgasms).

Another difference between women’s and men’s orgasms is their source, so to speak.  While virtually all male orgasms are a result of stimulation of the penis, female orgasms can come from a variety of places.  Many orgasms can result from stimulation of the clitoris (homologous to the penis).  Other orgasms result from stimulation of the “G spot.”  Some women have no trouble achieving orgasm from vaginal stimulation (such as simple intercourse).  Orgasms can also originate in other erogenous zones, notably the breasts (especially the nipples) and anus.  I have heard women speak of orgasms resulting from stimulation of the neck, toes, and arms.  Really, it just depends on what your body responds to.

So, those are the basics of the female orgasm and resolution.  I know I did not cover it all.  Have a question or a comment?  Go for it.

Female Sexual Arousal

What IS female arousal? With men, it is pretty straightforward to determine whether a man is aroused or not. Is the penis erect or not? Of course, there are nuances to this but, overall, that’s the litmus test for men. What physiological signs are present when a woman is sexually aroused?

When sexually aroused (usually a combination of psychological and physical stimulation), women’s breasts usually become enlarged and the nipples become erect. Of course, there are various reasons for enlarged breasts and erect nipples, but they are usually present to some degree when a woman is aroused. The enlargement of the breasts is usually slight enough that it is rarely noticed. The veins in the breasts also become more visible as the breasts swell. Additionally, the skin may flush during arousal especially on the chest and neck. This is most visible in fair-skinned individuals. Approximately 50-75% of women experience flush during arousal, while only about 25% of men experience flush.

During sexual arousal, a woman’s vagina and reproductive organs undergo several changes. The vaginal lining moistens with lubricating fluid within 10 to 30 seconds of the beginning of arousal. This fluid is believed to be the “sweating” of the vaginal walls. The sweating resulted from the increased blood supply and the engorgement of vaginal tissues. Also the vaginal walls lengthen and distend, which pulls the cervix and the uterus slowly back and up into the false pelvis (the part of the pelvis above the hip joint). The engorgement of the vagina is a type of vasocongestion, a phenomenon also seen in menstruation, REM sleep, allergic reaction, and deeply emotional responses.

The glans in the head clitoris also become swollen and erect like a penis. (The clitoris, after all, is homologous to the penis–see this illustration for a better idea of how much like a penis a clitoris is, or really vice versa.) This reaction to arousal varies in degree between women. The labia majora swell as do the labia minora, though to a lesser degree.

Women’s blood pressure, breathing, and heart rate increase considerably during sexual arousal. This happens in order to accommodate the increased blood supply to various parts of the body with sufficient oxygen. Muscles throughout the body also become tense because of this. These and the above signs of arousal occur during the first two stages of the human sexual response as outlined by Masters and Johnson: excitement and plateau.

There are various other individual idiosyncratic responses that can occur during sexual arousal. For instance, some women report unprovoked sneezing, increased ticklishness, and swollen lips. So the next time you lay eyes on the one that makes your heart jump remember what’s going on with your body. Comments or questions? You know where to leave them. Thanks!

Vaginal Rejuvenation

While there are a myriad of possible gynecological surgeries, which ones do women elect to have performed?  In the past tubal ligation and varying degrees of hysterectomy have been the most popular elective gynecological surgeries.  In the 1990s, though, elective c-sections began to boom.  Recently, however, a growing movement has developed in backlash to the increased number of unnecessary c-sections in the United States–both voluntary and involuntary.  Now, there is a new trend towards cosmetic gynecological surgeries such as “vaginal rejuvenation” procedures.

What are currently the most popular “vaginal rejuvenation” surgeries?  Labiaplasties are rising in popularity.  A labiaplasty is a plastic surgery that involves tightening of loose labial folds or removal of extra tissue of the vulva.  After childbirth, with age, because of disease, or because of genetics women may have labia that they feel is large or perhaps too loose.  Surgeons can perform reductions of this tissue to make it smaller and/or tighter feeling.  These surgeries can now be done with the assistance of laser, which are meant to help the healing process.  The American College of Obstetricians and Gynecologists (ACOG) issued a statement in 2007 stating that there is no documentation of the efficacy and safety of such a procedure.  The risks include those inherent with any surgical procedure (clots, bad reaction to anesthesia, etc), botched outcome leading to further complications or surgeries, and the ring of scar tissue created causing issues with childbirth.  A woman with such scar tissue would be less likely to be able to deliver vaginally, and would face enormous complications if she did.  Young women have labiaplasties more often than older women, thus the concern for childbirth.

Other “vaginal rejuvenation” surgeries include hymenorrhaphy and vaginoplasty.  Hymenorrhaphy is rarer than labiaplasty and bears fewer risks.  It is a simpler surgery in which an already ruptured hymen is recreated in order for the woman to prove (or feign) virginity.  Vaginoplasties are much more invasive and dangerous.  A vaginoplasty is performed in order to tighten or reconstruct vaginal muscles.  Reasons for vaginoplasty can include disease, childbirth, or other trauma to the vagina.  However, many women now seek vaginoplasties because they feel it will increase their pleasure and sensitivity during sex.  As the ACOG points out, though, there is no evidence to support this assumption.  Vaginoplasties are also very common among males seeking gender reassignment surgeries, as a vagina can be created out of penile or scrotal tissue.  Most associations and societies of plastic and cosmetic surgeons do not yet count or keep track of the abovementioned plastic surgeries, or have only recently begun tracking them.  So it is difficult to say how many such surgeries are performed every year.  However, it is clear even from the basic figures that the numbers of these elective surgeries are increasing exponentially every year.  (One figure shows that about 600 were performed in 2005, 1,000 in 2006, and over 4,000 in 2007.)  It is a whole other topic to discuss the socio-psychological reasons why women choose such surgeries, but what do you think?  Would you ever be willing to go under the knife for such a procedure?  Other comments or questions?  Shoot!