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Assignment 4: The Sexual Response Cycle According to Masters and Johnson

Differentiate the sexual response cycles of males and females. What are the differences between males and females, and what do they share in common?

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CHAPTER 4 Female Sexual Anatomy and Physiology

FEATURES

•  Global Dimensions Female Genital Mutilation in Various Parts of the World

•  Ethical Dimensions Should PMS Be Used as an Excuse for Socially Unacceptable Behaviors?

•  Gender Dimensions Breast Self-Examination

•  Multicultural Dimensions Breast Cancer More Deadly in African Americans

CHAPTER OBJECTIVES

• 1 Name and describe the parts of the female reproductive system, to include external and internal genitalia.

• 2 Discuss the role of breasts in sexual arousal and response, as well as in the reproductive function of lactation.

• 3 Explain the role of hormones as they pertain to sexuality.

• 4 Describe what occurs during menstruation, to include menarche, the menstrual cycle, and problems associated with each.

• 5 Cite various diseases that can affect the female reproductive system and the self-care procedures, as well as medical treatments, associated with these diseases.

go.jblearning.com/dimensions5e

Global Dimensions: Female Genital Mutilation

Amenorrhea

Breast Cancer

INTRODUCTION

One of the authors of this text was sitting at his desk preparing for an upcoming class. On the desk were diagrams of the female and male reproductive systems, colored pictures with various parts differentiated from others by different pastel colors and shading. Before long, a colleague walked into the office. The visitor was a professor of educational administration and the proud recipient of a baccalaureate degree in mathematics, a master’s degree in counseling, and a doctorate in educational administration. In short, this was an educated man, one on whom students and family relied and whose opinions were accorded the respect someone of his stature deserves. As he entered the office, he glanced at the desk and was fascinated with the reproductive system diagrams. When he inquired as to their purpose, he was told that they were to be used in a sexuality education class to help students learn about their sexual organs. It was then that he sheepishly admitted his own ignorance about the structure and function of the reproductive system. For the next 20 minutes, he and his colleague proceeded to discuss the reproductive systems of females and males, referring to the diagrams on the desk.

The only surprising aspect of this incident was the openness with which this educated man admitted his ignorance. In general, people know less about themselves, both physically and psychologically, than they know about cars or ecology or sports or politics or contemporary musicians or any of the hundreds of topics people care about or find fascinating. The less we know about our bodies, the less well equipped we are to keep them healthy. The more we know, the more choices we have and the better decisions we can make. Appropriate health maintenance should be valued similarly by males and females, and both genders need to adopt certain behaviors, such as periodic medical screenings, to maintain their health. However, men’s and women’s reproductive health issues are not the same.

The purpose of this chapter is to describe the anatomy of the female reproductive system as a step toward creating a comprehensive picture of human sexuality.

 The Female Reproductive System

Both females and males have external and internal genitals, or reproductive organs. We begin with the external female genitals and progress inward.

The External Genitals

The external female genitals are the mons pubis, labia majora, labia minora, clitoris, vestibule, and urethral opening (Figure 4.1). All of these organs together are called the vulva.

vulva

The female external genitalia.

The Mons Veneris

The mons pubis (also called the mons veneris, or mount of Venus) is the rounded, soft area above the pubic bone that becomes covered with hair at puberty. Since the mons contains numerous nerve endings, it can be sexually stimulated.

mons pubis (mons veneris, mount of Venus)

The rounded, soft area above the vaginal opening that becomes covered with hair at puberty.

The Labia Majora

The labia majora (major lips) are two large folds of skin whose main function is to protect the external genitalia. Unless the labia majora are spread apart, the other external genitalia are not visible. The outer surfaces of the labia majora also grow hair after puberty, and the inner surfaces remain smooth. Within the tissue of the labia majora are smooth muscle fibers, nerves, and vessels for blood and lymph.

labia majora

Two large folds of skin whose main function is to protect the external genitalia and the opening of the vestibule (defined later).

The Labia Minora

FIGURE 4.1 Female external reproductive organs.

The labia minora (minor lips) are two folds of skin lying inside the labia majora. Loaded with blood vessels and nerve receptors, the labia minora and their upper part, the clitoris, are very sensitive to stimulation. During sexual arousal, blood fills the labia minora, causing them to spread, making the vagina more accessible. Within the labia minora lie Bartholin’s glands. The glands slightly lubricate the labia during coitus (intercourse).

labia minora

Two folds of skin lying inside the labia majora, which contain numerous blood vessels and nerve receptors.

Bartholin’s glands

Small glands located within the labia minora that secrete a few drops of fluid during sexual arousal.

 Global DIMENSIONS: Female Genital Mutilation in Various Parts of the World

Female genital mutilation has been used throughout the world as a means of diminishing sexual stimulation. The result, the argument goes, is that fewer women participate in sexual intercourse outside marriage and fewer women engage in masturbation. Female mutilation can take several different forms. The most simple form is circumcision, whereby the clitoral hood is removed. In a clitoridectomy, the clitoris itself is surgically removed. Genital infibulation is the most complex procedure: The clitoris and the labia minora are removed, and both sides of the vulva are scraped raw and then stitched together. When the tissue grows together, only a small opening remains through which urine and the menstrual flow pass. During these procedures, it is unusual for sterile instruments to be used. Most of the time razor blades or broken glass is used to do the cutting, without the benefit of pain-reducing medications or disinfectants. Therefore, as you might imagine, aside from causing psychological trauma, female mutilation can result in serious medical complications. The combination of infections, bleeding, and pain can cause shock, gangrene, and even death.

Female mutilation is common in some African, Middle Eastern, and Asian countries. The United Nations estimates that 70 million girls and women have been subjected to female genital mutilation in Africa and Yemen. Mutilated women are also increasingly found in Europe, Australia, Canada, and the United States, primarily among immigrants from Africa and southwestern Asia (UNICEF, 2011a)—this in spite of the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) 1980 joint plan to lobby leaders of countries in which female mutilation is common to work toward eliminating this practice. A new statement, with wider United Nations support, was then issued in February 2008 (World Health Organization, 2008). Numerous other organizations and governments have publicly opposed female genital mutilation, even though the tendency is to avoid interference in cultural practices of sovereign countries. Grass-roots organizations, such as the Kenyan women’s organization Maendeleo ya Wanawake, and Tostan in Senegal, have also sprung up around the world with the goal of eliminating female genital mutilation. These groups conduct educational campaigns encouraging women to break the generational cycle of female genital mutilation by preventing their daughters from experiencing it. The prevalence of female genital mutilation is declining. It is measurably less common among younger women than older ones, and among daughters compared with their mothers. But progress is slow, and millions of girls remain threatened by the practice (UNICEF, 2011b).

The Clitoris

The clitoris is the most sensitive structure in the female body. This small organ contains two spongy bodies, the corpora cavernosa, that have the capacity to fill with blood during arousal. (The penis, a similar organ, contains spongy bodies that react to arousal in a similar way.) During sexual stimulation, the corpora cavernosa fill with blood, causing the clitoris to become erect. Popular knowledge about the sensitivity of the clitoris has led males to seek out and stimulate it to arouse their female sexual partners. Here is a case in which knowledge can have either a positive or a negative effect on sexual relationships. Men who carefully and delicately stimulate the clitoris may sexually arouse their partner, but those who rub incessantly will only irritate the clitoris and thereby irritate their partner.

clitoris

The structure located at the upper part of the labia minora that is homologous to the penis and is very sensitive to stimulation.

corpora cavernosa

A cavernous structure located within the clitoris and the penis that fills with blood during sexual excitement, causing erection.

The clitoris is covered by the clitoral hood. As can be seen in Figure 4.1, the hood is attached to the labia minora. One function of the clitoral hood is to protect the glans of the clitoris. When we discuss the male reproductive organs, we will observe that the foreskin of the penis protects the glans penis in a similar way.

clitoral hood

The skin covering the clitoris.

Knowing about the anatomy of the reproductive system offers guidance for sexual functioning, and the relationship of the clitoris, the clitoral hood, and the labia minora provides a case in point. During sexual excitement, the clitoris retracts under the clitoral hood. Therefore, stimulating the clitoris requires pulling back the clitoral hood, pulling the labia majora upward, or putting pressure on the hood or clitoris itself. For example, during sexual intercourse, the clitoris can be stimulated if the penis is positioned correctly. One position that will stimulate the clitoris is called “riding high.” With the female lying on her back, the male places his penis into the vagina so that its upper shaft rubs on the clitoris. Another option is for the penis to be pressed, thrusting downward, on the lower part of the labia minora so as to create downward movement of the hood and its contact with the clitoris. Many women, however, require additional manual stimulation of the clitoris to cause orgasm during intercourse.

Many variations exist in the female external genitals.

The Vestibule

When the clitoris is erect and the labia minora spread, the urethral and vaginal openings (called the vestibule) become visible.

vestibule

The area containing the vaginal and urethral openings.

The Urethral Opening

The urethral opening, where urine is excreted, is not generally considered a part of the reproductive system in females, although there is some evidence that women who do experience something akin to ejaculation do so through the urethra.

The Hymen

The hymen, a thin connective tissue containing a relatively large number of blood vessels, covers the opening of the vagina in women who have an intact hymen. The function of this tissue is unknown. Hymens vary in shape and size: A hymen may surround the vaginal opening (an annular hymen), bridge it (a septate hymen), or form a sievelike covering (a cribriform hymen) (Figure 4.2).

hymen

A thin connective tissue covering the opening of the vagina.

annular

Type of hymen that surrounds the vaginal opening.

septate

Type of hymen that bridges the vaginal opening.

cribriform

Type of hymen that creates a sievelike covering for the vaginal opening.

FIGURE 4.2 The various types of hymens.

Normally all forms of hymens have openings that are large enough to permit menstrual flow or the insertion of a tampon or a finger, but that are usually too small to permit an erect penis to enter without the hymen tearing. Historically the presence of an intact hymen was considered proof that a woman had never had intercourse. But the hymen can be ruptured by accident or by normal exercise, as well as by intercourse, so a tear in the tissue is not a reliable indication that a woman is no longer a virgin. The rupturing of the hymen during first intercourse generally does not result in a great deal of pain and bleeding, although some people expect it to do so. Pain is usually related to muscular tension due to anxiety or to entry of the penis into the vagina before the vagina is sufficiently lubricated; care and attention can ordinarily prevent it. A few drops of blood may be noticeable.

FIGURE 4.3 Organs of the female reproductive system.

The Internal Genitals

The female internal genitals consist of such structures as the vagina, uterus, fallopian tubes, and ovaries. These structures of the female internal genitalia, as well as relevant surrounding structures, are depicted in Figures 4.3 and 4.4.

The Vagina

The vagina is a hollow, tunnel-like structure, about 4.5 inches (11.4 centimeters) long, that opens outward to the vestibule and at the opposite end into the uterus. The vagina has several reproductive functions: It surrounds the penis and receives its ejaculate during intercourse, serves as the route of exit for the newborn, and provides an exit for menstrual flow. When the vagina is empty, its lips and walls are in contact, but during childbirth the vagina can expand wide enough for the baby to pass through, and during intercourse it can both expand and close tightly enough on a penis to provide sexual satisfaction. Soft transverse folds in the vaginal wall enable the vagina to expand, and muscle fibers within the walls enable it to contract, as they do in orgasm. No muscles surround the vaginal entrance (the introitus); however, the pubococcygeal and bulbocavernosus muscles that support the vagina can be voluntarily contracted so as to intensify sexual responsiveness by forcing the vaginal walls to close on the penis. Exercises to help women develop greater control of these muscles (called Kegel exercises after their proponent) are frequently recommended by sexual counselors (Kegel, 1952). To learn to control the pubococcygeal muscles, try the following:

• 1. Insert a finger into the vagina and contract muscles in that area until you feel the vagina squeeze the finger.

• 2. Practice squeezing and then relaxing these muscles—first slowly, then rapidly.

• 3. Practice the preceding exercise about three times daily until you feel you have voluntary control of the pubococcygeal muscles.

vagina

A hollow, tunnel-like structure of the female internal genitalia whose reproductive functions are to receive the penis and its ejaculate, serve as a route of exit for the newborn, and provide an exit for menstrual flow.

introitus

The vaginal entrance.

pubococcygeal muscle

A muscle that encircles the vagina and supports it.

bulbocavernosus muscle

A muscle that encircles and supports the vagina.

Kegel exercises

Exercises to help women develop greater control of muscles supporting the genitalia.

FIGURE 4.4 An anterior view of the female reproductive organs showing the relationships of the ovaries, fallopian tubes, uterus, cervix, and vagina.

The Grafenberg Spot

One would think that after centuries of studying the human body and its sexual nature there would be little room for disagreement regarding its function. Not so. The existence and the effect of the Grafenberg spot (G spot) provide a case in point.

Grafenberg spot (G spot)

An area located along the anterior wall of the vagina, several inches into the vaginal canal, that when stimulated in some women may result in sexual excitement and/or orgasm.

The stimulation of an area along the anterior (front) wall of the vagina, several inches into the vaginal canal and just below the bladder, appears to be sexually exciting for many females. This area is known as the Grafenberg spot, named after Ernest Grafenberg, the gynecologist who first noted its erotic potential (Figure 4.5) (Grafenberg, 1950). The presence of glands in this area has been known for some time (Skene, 1980), and it is these glands—called Skene’s glands—through which a type of ejaculate is expelled in some women when they experience orgasm by stimulation of the G spot (Grafenberg, 1950; Sevely & Bennett, 1978; Addiego et al., 1981; Belzer, 1981; Perry & Whipple, 1981; Zaviacic et al., 1988).

Skene’s glands

Glands located along the walls of the vagina that are thought to be analogous to the male prostate gland and the site from which some women eject a fluid during orgasm.

Others maintain that there is no one particular spot in the vagina that is more sensitive than others to stimulation. For example, the noted sexual therapist Helen Singer Kaplan believes there are many spots within the vagina that are sexually arousing, and the G spot is merely one of those (Kaplan, 1983). Masters and Johnson agree with Kaplan; they report that only 10% of the women they studied “had an area of heightened sensitivity in the front wall of the vagina or a tissue mass that fit the various descriptions of this area” (Masters, Johnson, & Kolodny, 1985). Although some women reported sensitivity in the front wall of the vagina, a study by Alzate and Londono (1984) could not locate a specific spot such as that described by Grafenberg. Heath (1984) found an area of erotic sensitivity and concluded that it is larger than previously described: about the width of the middle two fingers and at least two-thirds the length.

FIGURE 4.5 The location of the Grafenberg spot.

In a more recent study of female twins, 56% of the women studied reported having a G spot, even though there was determined to be no genetic basis for its existence (Burri, Cherkas, & Spector, 2010). However, there still remain skeptics. For example, some researchers explain the sensation on the anterior wall of the vagina as pressure and movement of the clitoris during vaginal penetration and not a distinct G spot area (Foldes & Buisson, 2009). At the 2009 meeting of the International Society for the Study of Women’s Sexual Health Congress, the Journal of Sexual Medicine held a debate among experts regarding the existence of the G spot. The conclusion was that more research is needed to determine whether the G spot actually exists (Jannini et al., 2010).

The Female Prostate

The existence of a female prostate and ejaculate, although controversial, was first described centuries ago. In the 4th century, several Chinese Taoist texts mentioned female ejaculation. In the 7th century, the Indian Kamasutra mentioned it, as did Aristotle (in 300 B.C.) and Galen (in the 2nd century) (Korda, Goldstein, & Sommer, 2010).

That glandular tissue exists in the area of the G spot is not debatable. The pathologist Robert Mallon (1984) conducted autopsies on women and found evidence of this glandular tissue, as did Heath (1984). Both of these researchers found prostatelike glandular tissue in the front wall of the vagina. When the substances within these glands were analyzed, they were found to contain fluids similar to those found in the male prostate. Hence, some sexuality experts have concluded that there are a female prostate (the Skene’s glands) and a female ejaculate. Further evidence for a female ejaculate is offered by Addiego and colleagues (1981), who analyzed the fluid expelled by females at the time of orgasm and found it to contain an enzyme (prostatic acid phosphatase, or PAP) characteristic of semen. However, when Goldberg and associates (1983) studied this ejaculate, they concluded that it was similar to urine. Alzate and Hoch (1986) also found ejaculate secreted through the urethra. To complicate matters further, a study conducted by Belzer and associates (1984) concluded that the ejaculate obtained from women contained significantly more prostatic acid phosphatase than did their urine. More recently, researchers using ultrasound and biochemical analysis concluded that there is glandular tissue surrounding the length of the female urethra containing a duct that secretes fluid during orgasm. Upon analysis, that fluid was more similar to prostate secretions than urine (Wimpissinger et al., 2007). Obviously, further study is needed to confirm the existence of a female ejaculate beyond any doubt.

That some women expel a fluid from the vagina during orgasm has been demonstrated. The prevalence of this phenomenon remains unknown. Whether this fluid is similar to that of the male prostate is a matter of much research and debate. What is not discussed or researched, however, is the concern first expressed by the Boston Women’s Health Collective (1998) regarding the possibility that the G spot orgasm will become a new “ideal” for the sexually liberated woman. It would indeed be unfortunate if this new ideal created pressure on women who do not experience erotic feelings when the Grafenberg spot is stimulated and, therefore, perceive themselves to be inadequate sexually. When the media popularize sexual information, as they did with the Grafenberg spot, often education is needed to remind the public about the many paths to sexual fulfillment. This is particularly true today.

The Uterus

At the top of the vagina lies the uterus, a pear-shaped hollow organ with muscular walls. Its function is to nurture the developing embryo and fetus. Except during pregnancy, the uterus is about 3 inches (8 centimeters) long, 3 inches wide at the top, and 1 inch (2.5 centimeters) thick. The uterus extends into the vagina at its cervix; the actual opening to the uterus in the cervix is called the os. The upper two-thirds of this cavity is called the corpus, and the top end is called the fundus. Most uteruses tilt forward (that is, they are anteflexed) over the bladder; approximately 20% tilt backward (retroflexed) (Figure 4.6). Women with retroflexed uteruses are more likely to experience discomfort during menstruation and may have more difficulty in inserting a diaphragm as a result of the angle of the cervix. Contrary to widespread belief, however, the ability to conceive is in no way affected by the position of the uterus.

uterus

A pear-shaped hollow structure of the female genitalia in which the embryo and fetus develop before birth.

cervix

The mouth of the uterus, through which the vagina extends.

os

The opening to the uterus.

corpus

The upper two-thirds of the uterus.

fundus

The upper end of the uterus, closest to the opening of the fallopian tubes.

FIGURE 4.6 Various positions of the uterus: (a) retroflexed and (b) anteflexed.

The uterus consists of three layers. The outermost layer, the perimetrium, is very elastic, enabling the uterus to accommodate a growing embryo during pregnancy. The middle layer, the myometrium, consists of smooth muscles, whose ability to contract helps push the newborn through the cervix and into the vagina (which during childbirth acts as the birth canal). The innermost layer of the uterus is the endometrium. This layer is loaded with blood vessels and can therefore provide the nourishment necessary to sustain a developing fetus. It builds up and partly sloughs off as the menstrual flow in every menstrual cycle, unless fertilization takes place. Figure 4.7 depicts the anatomical relationships of the three layers of the uterus.

perimetrium

The outermost layer of the uterus, sometimes termed the serosa, a very elastic layer that allows the uterus to accommodate a growing embryo and fetus.

The middle layer, the myometrium, consists of smooth muscles, whose ability to contract helps push the newborn through the cervix and into the vagina (which during childbirth acts as the birth canal).

myometrium

The middle layer of the uterus, consisting of smooth muscle that aids in the pushing of the newborn through the cervix.

endometrium

The innermost layer of the uterus, to which the fertilized egg attaches and by which it is nourished as it develops before birth, which is partly discharged (if pregnancy does not occur) with the menstrual flow.

FIGURE 4.7 Layers of the uterine wall.

The Fallopian Tubes and the Ovaries

At the fundus, the uterus opens into the two fallopian tubes (we will use this more common name, although oviduct might be more appropriate). At the other end of each tube is an ovary, the organ that produces and stores the ova, or eggs. When a female is born, each of her ovaries contains approximately 40,000 to 400,000 eggs. Every egg has the potential to be fertilized by a sperm to become an embryo. After the girl reaches puberty, one of these eggs is usually discharged through the wall of one of her ovaries during each menstrual cycle. The egg develops inside a capsule called a Graafian follicle and is discharged when it has matured. The discharged egg, now matured and freed from its capsule and the ovary, is ready to be fertilized by a male’s sperm. When the follicle ruptures to discharge its egg, the empty follicle, now a yellowish structure called the corpus luteum, secretes a hormone (progesterone) that signals the endometrium to prepare for a fertilized egg. Progesterone and estrogen, another hormone produced by the ovaries, play significant roles in menstruation, birth, growth, and aging.

fallopian tubes (oviduct)

The routes through which eggs leave the ovaries on their way to the uterus, in which fertilization normally occurs.

ovary

A structure of the female genitalia that houses ova before their maturation and discharge and that produces estrogen and progesterone.

Graafian follicle

A part of the ovary from which a mature egg ruptures, allowing the corpus luteum to develop in the location where the egg was released.

corpus luteum

A yellowish structure that develops in the Graafian follicle at the discharge of an ovum and that produces progesterone and estrogen.

progesterone

A hormone secreted by the corpus luteum signaling the endometrium to develop in preparation for a zygote.

estrogen

A hormone produced by the ovaries whose level in the blood helps control the menstrual cycle.

When the ovum is discharged from the ovary, it is directed into the fallopian tubes. As shown in Figure 4.4, these tubes serve as routes for ova to reach the uterus. The newly released ovum is caught by the fingerlike end of the fallopian tube, called a fimbria, and is guided into the cone-shaped open end of the tube. If fertilization takes place, it usually takes place there.

fimbriae

The fingerlike ends of the fallopian tubes that catch the ova when they are discharged from the ovaries.

Whether fertilized or not, the ovum continues on its journey through the tube, moved along in a sweeping motion by tiny hairlike structures called cilia. The destination of the fertilized ovum is the endometrium in the uterus, where it becomes attached and continues its development. An unfertilized ovum also travels to the endometrium, then disintegrates, and eventually is expelled through the vagina, along with some of the endometrium, in the process called menstruation. (Once an ovum is expelled, the menstrual cycle is completed. Soon an ovary will discharge another mature egg and the process will begin again.)

cilia

Hairlike structures that guide objects, such as ova, moving past them.

FIGURE 4.8 The female breast.

It should be noted that occasionally a woman may produce more than one egg per cycle, thereby becoming prone to multiple births. Fertility drugs, which may result in multiple births, are suspected of causing the maturation of several eggs per cycle. Sometimes the fertilized egg may attach in the abdominal cavity or the fallopian tube rather than in the uterus. This is termed an ectopic pregnancy.

ectopic pregnancy

The attachment and development of the zygote in a location other than in the uterus.

 The Breasts

Although the female breasts are not reproductive organs, they do have significance in sexual arousal and response, and they serve an important reproductive function in providing milk for the newborn infant. Each breast contains about 15 to 20 clusters of milk-secreting structures called mammary glands (Figure 4.8). Each of these mammary gland clusters has an opening to the nipple, where the milk ducts open. The stimulation of the newborn’s sucking on the nipple causes the pituitary gland to secrete a hormone called prolactin, which in turn stimulates the production of breast milk.

mammary glands

Milk-secreting glands located in the female breast.

prolactin

A pituitary hormone that stimulates the production of milk from the mammary glands.

Most of the breast is fat and connective tissue. Except for small muscles in the area of the nipple and areola (the darkened skin around the nipple), there are no muscles in the breast. Because the breast is muscle-free, exercises to increase breast size are ineffective. Over the years the breasts may hang lower than normal if the ligaments are stretched by lack of support or by jostling (for example, not wearing a bra while jogging).

areola

The darkened part of the breast immediately surrounding the nipple.

The nipples—of men as well as women—are richly supplied with nerve endings that respond with pleasurable sexual feelings when stimulated. During sexual arousal the nipples become erect. The size of the breasts or their shape is not related to sensitivity. Women with either small or large breasts may be equally sexually stimulated by the fondling of the breasts. Though some have characterized our society as making a fetish of large breasts, preferences in breast size and shape vary from individual to individual. It should be noted, however, that although breast size varies, extent of glandular tissue is comparable in all women’s breasts. Because the amount of glandular tissue is the same, women with small breasts produce the same amount of breast milk after childbirth as women with larger breasts and are therefore as successful breastfeeding their babies as are women with larger breasts.

Our society has so emphasized breast size that many women have their breasts reconstructed. In the past, liquid silicone was injected to enlarge the breast, but approximately 60% of women experienced problems such as infection, deformity, or exceptional hardness of the breast. More recently, silicone pouches containing saline solution have been implanted to reshape the breast. However, in 1992, in response to reported breakage of the pouches, the Dow Chemical Company, the largest manufacturer of silicone pouches, stopped manufacturing them and agreed to pay for their removal for women who so desired. The most recent research, however, indicates that silicone implants are not the health issue previously thought. In a study of the research related to silicone breast implants, the Institute of Medicine (a subgroup of the National Academy of Sciences) found no convincing evidence that chronic disease was more likely to develop in women with silicone breast implants than women without implants (Reuters, 1999). Furthermore, during a lawsuit against breast implant manufacturers, a federal judge appointed a panel of scientists to study the issue and report their findings to the court. The court-appointed panel found no convincing evidence that silicone breast implants cause disease of the immune system as alleged in the lawsuit. The Food and Drug Administration also approved silicone-gel implants for breast enhancement in 2003. Silicone pouch implants are still regularly used in breast reconstruction for women who have had a radical mastectomy due to cancer of the breast.

We also need to be concerned about other health issues regarding the breast, such as cancer of the breast. (We discuss this in greater detail later in the chapter.) Suffice it to say here that women need to obtain periodic medical checkups by a health professional to make sure that any abnormalities are identified early, thereby increasing the likelihood that treatment will be successful and as noninvasive as possible.

Table 4.1 reviews the functions of the female reproductive organs.

 The Hormones

The size and shape of breasts vary among women.

What happens at the sight of an attractive person in a skimpy bathing suit? If the stimulus is sufficiently interesting, it can result in the first stages of sexual response—for example, increased heart rate, vaginal lubrication, and erection of the penis or clitoris. How does the visual image result in these physical changes? The chain of events is rather complex. It starts with the hypothalamus, a structure in the brain that, either through direct nerve pathways or through chemicals called releasing factors, can instruct various body parts to function. The hypothalamus might be said to serve as a bridge between external stimuli and physiological responses. But let us go back to the bathing suit. Two things happen: (1) When the individual perceives the external stimulus as sexually exciting, the hypothalamus “tells” the pituitary gland to secrete its hormones, and (2) these chemicals stimulate the adrenal gland to secrete its hormones and the testes and ovaries to secrete their hormones. These secretions change the blood flow (producing vasocongestion), the heart rate, breathing, vaginal moistness, and so on.

hypothalamus

A structure in the brain that controls the pituitary gland and is directly connected by nerve pathways to various organs of the body.

releasing factors

Chemicals released from the hypothalamus that affect the function of various body parts.

TABLE 4.1 Functions of the Female Reproductive Organs

These powerfully acting hormones are chemical substances that influence organs and tissues. They are produced by endocrine glands, glands that secrete their products into the bloodstream. The thyroid, for example, secretes a hormone that travels to the heart and increases the heart rate. The adrenal gland secretes the hormone adrenalin, which travels to the bronchial tubes of the lungs and dilates them. As we have just seen, the secretions of several glands are involved in sexual response.

hormone

A chemical substance secreted by a ductless gland, which is carried to an organ or tissue where it has a specific effect.

endocrine glands

Glands that secrete their products into the bloodstream.

The pituitary, a pea-shaped gland located at the base of the brain, serves as a sort of master gland to the others in the system. It stimulates the other glands to release their hormones. The front part of the pituitary secretes three sexual hormones, called gonadotropins, which act on or stimulate the gonads (the testes and ovaries). The gonads are also endocrine glands, and they produce their own hormones. The three gonadotropins are follicle-stimulating hormone (FSH); luteinizing hormone (LH), often called the interstitial-cell-stimulating hormone (ICSH) in males; and prolactin (produced only during pregnancy and breastfeeding). Once stimulated by these gonadotropic hormones, the gonads produce their own hormones: estrogens, progesterones, and androgens. The adrenal gland also secretes androgen directly.

pituitary

The “master gland,” an endocrine gland located at the base of the brain that stimulates the other endocrine glands to produce their hormones.

gonadotropins

Sexual hormones secreted by the pituitary that stimulate the gonads to produce their hormones.

gonads

The male testes and the female ovaries, which produce gonadotropin hormones responsible for the development of secondary sexual characteristics.

follicle-stimulating hormone (FSH)

A hormone, secreted by the anterior portion of the pituitary gland, that “instructs” the ovaries to prepare an egg to be released from a follicle.

luteinizing hormone (LH)

A hormone, secreted by the anterior portion of the pituitary gland, that stimulates ovulation.

interstitial-cell-stimulating hormone (ICSH)

A hormone, secreted by the anterior portion of the pituitary gland in males, that stimulates the production of sperm.

In women, estrogens and progesterones regulate the menstrual cycle, with estrogens important in producing vaginal lubrication. Although estrogens and progesterones have no known function in men, the presence of too much estrogen in the male body can lower interest in sexual activity and may result in enlargement of the breasts. Androgens affect the sex drive of both men and women: The presence of too much causes excessive sexual appetite, the presence of too little androgen decreases sexual interest. FSH stimulates cells in the seminiferous tubules (called spermatocytes) to produce sperm.

androgens

Male sex hormones.

spermatocytes

Cells that develop through several stages to form sperm.

Despite the fact that hormones account for and influence sexual differences, males and females produce the same hormones. Estrogens and progesterones are considered female hormones and androgens male hormones, but both males and females produce all three. They do differ in the amounts they produce, however. For example, males have levels of the strongest androgen (testosterone) 10 times those of females, and females have significantly more estrogens than males. Obviously, too, males and females differ in the organs activated by the hormones. Long before we begin to think about hormones and our sexuality, hormones have already had significant effects.

testosterone

The male sex hormone produced in the testes that is responsible for the development of male secondary sexual characteristics.

 Menstruation

At some time during puberty, a girl reaches menarche; that is, she has her first menstrual cycle. Then, and cyclically thereafter unless she is pregnant, blood (actually the blood-enriched endometrium) is discharged (or flows) from her uterus through her vagina for several days. The Latin origin of the word menstruation is mensis, meaning “month,” because the menses, or periods, supposedly occur monthly. Actually they are not so predictable. Between menarche and menopause, when menstruation ceases, a woman’s menstrual cycle may stabilize in a 28- to 30-day pattern (20- to 40-day cycles are also quite normal), or it may never stabilize. Cycles may vary in length from period to period, or they may be stable for a long time, fluctuate, and become stable again. Menstruation has been called the “curse,” the “monthly sickness,” and worse, but it is a normal physiological response to hormonal activity.

menarche

The time when a female begins her first menstrual cycle, usually at 8 to 16 years of age.

menstruation

The cyclical emission of the blood-enriched endometrium when pregnancy does not occur.

Menarche

The reason menstruation begins when it does is not exactly known. One hypothesis relates to the increase in body fat at puberty as a result of hormonal secretions. Evidence for this hypothesis can be found in long-distance runners. Many women who jog long distances lose considerable weight and body fat. It is not uncommon for such women to experience secondary amenorrhea; that is, they no longer menstruate regularly. In fact, some experts estimate that as many as 50% of women runners experience a cessation of menstruation (Barrack et al., 2010). In addition, women suffering from anorexia nervosa—a condition in which the woman is so preoccupied with being thin that she eats very little and loses a great deal of body weight and fat—often lose their periods. In truth, though, no one really knows why women joggers or anorexics cease to menstruate, and, at least for the joggers, there appears to be more going on than just a loss of body fat. Other studies have found that many thin female joggers continue to menstruate, and many heavier ones do not.

amenorrhea

The absence of menstruation in a woman who should be menstruating.

Menstrual Physiology

The menstrual cycle begins when the pituitary gland secretes two hormones: FSH, which stimulates the growth, or “ripening,” of follicles in the ovary; and LH, which stimulates the ovary to release one egg, that is, to ovulate. Once the egg is released, the area from which it was released (the Graafian follicle) becomes a yellow body (corpus luteum). The Graafian follicle secretes the hormone estrogen, and the yellow body secretes progesterone and estrogen. Progesterone causes the lining of the uterus to thicken and store nutrients in preparation to receive, implant, and nourish a fertilized egg, called a zygote. If the egg is not fertilized, the yellow body degenerates and thus becomes unable to secrete progesterone any longer. The lack of progesterone is a signal to expel the unneeded endometrium. This tissue, which is gradually shed over the course of a few days, is the menstrual flow. The cycle is then ready to begin anew.

zygote

A fertilized egg.

Phases of the Menstrual Cycle

Figures 4.9 and 4.10 depict the roles of hormones in the menstrual cycle and its phases. The first phase is termed the proliferative phase. It is during this phase that FSH production is increased by the pituitary gland, which in turn stimulates the follicles in the ovaries to mature. The follicles then can produce estrogen, which causes the endome-trial lining of the uterus to thicken and prepare for the implantation of the zygote. The pituitary then increases production of LH in response to the elevated levels of estrogen in the bloodstream, causing one follicle to prepare to expel an ovum (the Graafian follicle), and the proliferative phase proceeds until ovulation.

proliferative phase

The first part of the menstrual cycle, during which FSH production is increased and the follicles are maturing.

FIGURE 4.9 Hormones from the hypothalamus control the release of hormones from the pituitary gland, which in turn regulates production of ova and sex hormones from the ovaries. Note how the rise and fall of the hormone level is related to the building up and sloughing off of the uterine lining.

FIGURE 4.10 Changes in relative concentrations of hormones during ovulation and menstruation.

The secretory phase of the menstrual cycle begins once ovulation occurs and entails continued secretions of LH, which stimulate the development of the corpus luteum. The corpus luteum secretes progesterone, causing further thickening and engorgement of blood of the endometrium. If implantation does not occur, the pituitary shuts down production of FSH and LH, causing degeneration of the corpus luteum. The result is a decrease in the secretions of estrogen and progesterone.

secretory phase

The second part of the menstrual cycle, during which ovulation occurs and the production of LH stimulates the development of the corpus luteum.

The next phase of the menstrual cycle is the menstrual phase, in which the endometrial lining of the uterus is sloughed off as the menstrual flow.

menstrual phase

The part of the menstrual cycle during which the endometrial lining is sloughed off as the menstrual flow.

Some sexuality experts divide the menstrual cycle into three different phases: the follicular phase, ovulation, and the luteal phase. The follicular phase coincides with the menstrual and proliferative phases, ovulation is marked by the discharge of the ovum from the Graafian follicle, and the luteal phase is the same as the secretory phase. This categorization pertains to changes in the ovaries, whereas the previous categorization refers to changes in the uterus.

follicular phase

The part of the menstrual cycle during which menstruation occurs and the pituitary increases the production of FSH so the follicles mature: a combination of the menstrual and proliferative phases.

ovulation

The part of the menstrual cycle when the ovum is discharged from the ovary.

luteal phase

The same phase of the menstrual cycle as the secretory phase, which includes ovulation and the production of LH from the corpus luteum.

As noted in Figure 4.10, in a 28-day cycle ovulation occurs on day 14, with the menstrual flow lasting for 4 days. The great variation in the menstrual cycle—among women and even in any one woman—should be emphasized. The 28-day cycle, although often spoken of as the cycle, is not very common. Furthermore, in spite of menstrual cycles’ differing in length, there is little difference in the luteal phase of these cycles. That is, regardless of the length of the menstrual cycle, once ovulation occurs, it basically takes 14 days until menstruation begins. For example, if a woman’s cycle is 42 days long, she will ovulate on day 28, and 14 days later she will menstruate; if her cycle is 30 days long, she will ovulate on day 16 and will still menstruate 14 days later.

Effects of Menstruation on the Body and Mind

Menstruation can have several physical and emotional effects, which vary greatly from woman to woman and from one cycle to another. Eighty-five percent of women of reproductive age experience physical or emotional changes associated with their menstrual cycle, and approximately 40% of women are bothered by menstrual cycle–related conditions such as premenstrual syndrome or premenstrual dysphoric disorder (Ballagh & Heyl, 2008). It is estimated that 2.5 million women are affected by menstrual disorders each year (Clayton, 2008). There is evidence that some 10% of women take time off from work, school, or other activities because of menstrual discomfort (Patterson, 1990). Some women report cramps, backaches, and pimples; others report none of these symptoms. Some women report feeling depressed, bloated, nervous, or weak, and others do not.

Menstruation can affect a woman’s body and mind. Cramps and backaches can occur, as well as feelings of nervousness or depression. Different women are affected differently by menstruation—some women have minor symptoms whereas others have symptoms that are more severe.

Whether a woman experiences any of these effects—be they physical or emotional—may be a function of what she expects to experience. Evidence for this hypothesis does exist. For example, when researchers conducting studies of menstruating women inform the women of what the study is about, women report more of these symptoms than when they do not know what is being studied (Brooks, Ruble, & Clark, 1977; Ruble & Brooks-Gunn, 1979). Because many of these symptoms cannot be objectively measured, what a woman expects to feel may create a self-fulfilling prophecy. That is not to say women do not experience real discomfort; rather, the mind may affect the amount of discomfort experienced.

Stress researchers have determined that the mind–body connection is a real one. That is, with certain actual illnesses and diseases, either the mind affects the body so as to prepare it to become ill or the mind changes the body in a way that makes the illness worse than it might otherwise be (Greenberg, 2011). Other factors that might influence menstrual symptoms include diets too high in saturated fats, a lack of regular exercise, and work in extremely cold environments (Greenwood, 1986; Barnard et al., 2000).

The preceding discussion is not meant to negate the real physical and emotional effects of menstruation. For example, depending on one’s age, and whether one has given birth to a child or not, cramping associated with menstruation can vary. Teenagers and perimenopausal women—those in the period between the beginning of menopause and the complete cessation of a woman’s period—report worse cramping than is usual, whereas women who have given birth to a child report less cramping.

Menstrual Problems

Several conditions associated with menstruation require special attention. Among these conditions are dysmenorrhea, amenorrhea, and premenstrual syndrome.

Dysmenorrhea

Painful menstruation is termed dysmenorrhea. Many women experience some discomfort and pain during some menstrual cycles, and other women experience discomfort and pain regularly. It has been estimated that 70% to 90% of menstruating women have some degree of menstrual problems on a regular basis (Sommerfield, n.d.). Women may experience severe abdominal cramping, a bloated feeling, headaches, backaches, and nausea. An estimated 10% to 15% of women experience menstrual pain each month severe enough to prevent normal daily function at school, work, or home (Smith, 2012).

dysmenorrhea

Painful menstruation.

The cause of primary dysmenorrhea—that is, pain during menstruation—is not specifically known. Many health practitioners identify the cause as prostaglandins, substances produced by body tissues that act as hormones. Prostaglandins, which are found in unusually high amounts in women with dysmenorrhea, cause the muscles in the uterus to contract. This contraction causes pain and cuts off some of the blood supply (with its oxygen) to the uterus, thereby causing more discomfort.

primary dysmenorrhea

Painful menstruation, the cause of which is unknown.

prostaglandins

Hormonelike substances produced by body tissue that may cause dysmenorrhea.

To treat primary dysmenorrhea, physicians sometimes prescribe antiprostaglandin medications such as naproxen (Aleve), Anaprox, or Ponstel. These medicines inhibit the production of prostaglandins and relieve pain, dizziness, headache, nausea, vomiting, and irritability in many women. Many women who do not use prescription drugs find aspirin or ibuprofen helpful in relieving pain (these also somewhat inhibit prostaglandin production). Other remedies proposed for dysmenorrhea include eating more fish and vegetables and less animal fats and taking calcium, vitamin B, and magnesium supplements. Drinking plenty of fluids has also been recommended, because it seems that when the body is dehydrated, the hormone vasopressin is secreted. Vasopressin conserves body fluids, an effect that is not what a woman feeling bloated needs. Oral contraceptives can also help relieve menstrual pain by eliminating ovulation and thereby decreasing the amount of prostaglandin produced (American College of Obstetricians and Gynocologists, 2009). In addition, placing a heating pad on the abdomen, lightly massaging the abdomen with the fingertips (effleurage), drinking warm beverages, taking a warm shower, doing waist-bending exercises, having an orgasm, and walking may alleviate some menstrual pain.

Secondary dysmenorrhea is painful menstruation caused by some other identifiable condition. For example, endometriosis (a condition in which endometrial cells attach and develop on some body tissue other than the uterus) can cause secondary dysmenorrhea, as can pelvic inflammatory disease, uterine tumors, and blockages of the opening to the uterus (the os). In these cases, treatment consists of finding and removing the cause of the menstrual pain, which may require surgery or medication.

secondary dysmenorrhea

Painful menstruation caused by some identifiable condition such as endometriosis.

endometriosis

The growth of the endometrium uterine lining at a location other than in the uterus.

Amenorrhea

Amenorrhea is the absence of menstrual flow. If a woman has never menstruated and is 18 years or older, her condition is called primary amenorrhea. If menstruation ceases after menarche, the condition is called secondary amenorrhea. Amenorrhea may be caused by pregnancy, malfunctioning of the ovaries, cysts or tumors, disease, hormonal imbalance, poor nutrition, or emotional distress. It may also be caused by strenuous exercise of the sort done by runners and young dancers (Koutedakis & Jamurtas, 2004; Torstveit & Sundgot-Borgen, 2005). The causes of amenorrhea in physically active women are not known. Some experts hypothesize that exercising women experience a decrease in body fat that may contribute to the cessation of their periods, as it does in anorexic women. Lower body fat may interfere with production of the amount of estrogen needed to menstruate. Among female athletes, amenorrhea is quite common (Mayo Clinic, 2007a), and it is suspected the cause is a combination of low body fat, the stress upon the body as a result of strenuous physical exercise, and the psychological stress associated with competition. Although the actual cause of amenorrhea in female athletes is difficult to determine, it does not follow that some physical condition does not exist in any one woman—athlete or not—that can be identified as the cause of her menstrual problem. It is advised that women whose menses cease consult their physicians to discuss any conditions or illnesses that are treatable.

primary amenorrhea

A condition in which a woman of age 18 years or older has never menstruated.

secondary amenorrhea

A condition in which a woman has ceased menstruating after menarche.

The fear of pregnancy also has been known to create enough anguish and anxiety in sexually active women to cause a cessation of menses. Fearing pregnancy, many couples wait with bated breath for the evidence that the woman is not pregnant—menstruation. A slight delay in her period (not unusual) makes the woman anxious about the possibility of an unwanted pregnancy. Her anxiety can then further delay menstruation or create amenorrhea. Thus a vicious cycle develops that only a pregnancy test or the menstrual flow can break. Any woman who has been sexually active and has missed more than one period should have a pregnancy test.

Premenstrual Syndrome

Some women experience mood changes and other physical and emotional discomforts just before their menstrual periods. This condition is referred to as premenstrual syndrome (PMS). In fact, more than 150 disorders have been associated with premenstrual syndrome; some of the more common ones are depression, tension, anxiety, mood swings, irritability or anger, difficulty in concentrating, lethargy, weight gain, fluid retention, bloating, breast soreness, joint or muscle pain, nausea, vomiting, and headaches (Mayo Clinic, 1998). It has been estimated that at some time during their reproductive years 75% of women experience PMS (Mayo Clinic, 2007b).

premenstrual syndrome (PMS)

Marked mood fluctuation during the week before menstruation, accompanied by physical symptoms.

Premenstrual syndrome was described by Katharina Dalton, a leading researcher in the treatment of PMS, in Once a Month (1979): “Once a month with monotonous regularity, chaos is inflicted on American homes as premenstrual tension and other menstrual problems recur time and again with demoralizing repetition.” Reading this, many women found solace in the fact that other women had similar experiences each menstrual cycle. It is undeniable that many women do experience something akin to PMS fairly regularly (see Table 4.2).

TABLE 4.2 Premenstrual Symptoms

Source: Reproduced from the National Women’s Health Center. Premenstrual Syndrome. 2010. Available:http://www.womenshealth.gov/faq/premenstrual-syndrome.cfm.

There is no laboratory test or other sure way to diagnose premenstrual syndrome. Doctors rely on the woman’s menstrual history, often requesting that patients keep a diary of the onset, duration, and the nature and severity of symptoms for at least two menstrual cycles. If symptoms such as those cited are present in the week before a woman’s period, subside as her period starts, and are absent the week after her period, she is diagnosed as having PMS. This diagnosis is important not only to determine the treatment to recommend but also to help screen out other conditions commonly confused with PMS, such as contraceptive side effects, dysmenorrhea, eating disorders, substance abuse, depression, and other psychiatric disorders.

There have been numerous theories about the causes of PMS. These are described in the following list, along with the recommended treatment based on the theory of causation.

• 1. Prostaglandins. As a woman’s uterine lining begins to shed during the menstrual cycle, prostaglandins (hormones) are released into her bloodstream. As the prostaglandins build up, they cause the uterine walls to become tense and to contract, resulting in cramping. As with dysmenorrhea, antiprostaglandin medications are recommended, such as aspirin, acetaminophen (for example, Tylenol or Datril), naproxen (Aleve), or ibuprofen (Motrin, Advil, or Nuprin).

• 2. Progesterone. Progesterone builds up during the menstrual cycle, causing PMS symptoms. Antiprogesterone medications are recommended to alter the menstrual cycle (speeding or delaying the onset of bleeding).

• 3. Natural opiates. Women experience a drop in the level of the neurotransmitter beta-endorphin, which is manufactured in the brain the week before the menstrual flow. This neurotransmitter has been described as the body’s natural opiate in that it alleviates pain and generally makes you feel good. Treatment involves administering the drug naloxone, which maintains high levels of beta-endorphins.

• 4. State of mind. The symptoms of PMS are the result of brain activity—that is, the mind. Moods, perceptions, thoughts, ideas, self-confidence, and self-image are “choreographed” by the brain premenstrually. Treatment, therefore, entails counseling and other means to help women change their states of mind.

Other treatments include the following:

• 1. Birth control pills to stop ovulation.

• 2. Medications such as injectable medroxyprogesterone acetate (Depo-Provera) to stop ovulation and menstruation temporarily in severe cases.

• 3. Antidepressants in lower dosages than usually prescribed for depression, such as fluoxetine hydrochloride (Prozac), sertaline hydrochloride (Zoloft), paroxetine hydrochloride (Paxil), and venlafaxine hydrochloride (Effexor), if symptoms are mainly emotional.

• 4. A vegetarian diet.

• 5. Naturopathic medicine that includes lifestyle and dietary changes and may consist of nutritional supplements, botanical medicines, homeopathy, Chinese medicine, acupuncture, hydrotherapy, manipulation, physical therapy, or minor surgery (Phalen, 2000).

In addition, the following is recommended (Mayo Clinic, 2007b):

• 1. Maintain a healthy body weight.

• 2. Lower the intake of salt and salty foods, especially before the period, to reduce fluid retention and bloating.

• 3. Avoid alcohol before the period to minimize depression and mood swings.

• 4. Avoid caffeine, such as in coffee, cola, and tea, to reduce moodiness, tension, and breast tenderness.

• 5. Increase the intake of carbohydrates such as breads, potatoes, cereals, vegetables, and rice.

 Did You Know . . .

When the American Psychiatric Association included PMS in its Diagnostic and Statistical Manual of Mental Disorders IV as an illness, terming it late luteal phase dysphoric disorder (LLPDD), some people objected to the potential negative economic and social impact for all women. They believed it promoted a view of women as unreliable and unstable. However, others were grateful that women could then collect health insurance for treating PMS and that research would be focused on the condition.

late luteal phase dysphoric disorder (LLPDD)

A type of premenstrual syndrome in which mental and emotional symptoms occur the week before menstruation. This is the name given to that condition by the American Psychiatric Association.

• 6. Exercise regularly to enhance the sense of well-being.

• 7. Reduce stress by getting plenty of sleep, practicing a relaxation technique regularly, and trying yoga or massage.

Premenstrual Dysphoric Disorder

As many as 10% of women experience premenstrual symptoms so severe they cannot maintain their daily routines (Mayo Clinic, 2008). Some experts believe this is a result of a condition they term premenstrual dysphoric disorder (PMDD). PMDD has been described as a supercharged PMS, and is cited in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. PMDD’s symptoms include

• • A marked depressive mood

• • A decreased interest in usual activities

• • Lethargy, fatigability, or lack of energy

• • Hypersomnia (falling asleep when not wanting to) or insomnia (difficulty falling asleep)

Exercising regularly and maintaining a healthy body weight are two strategies that are recommended to help women limit the severity of their menstrual and premenstrual symptoms.

There is disagreement among women’s health specialists about whether PMDD should be categorized as a “mental disorder.” Some believe that classifying menstrual problems as a mental disorder stigmatizes women. As one psychologist argued: “It’s a label that can be used by a sexist society that wants to believe that women go crazy once a month” (Daw, 2002). Others believe a PMDD classification acknowledges women’s feelings and focuses researchers’ attention on developing medications to help premenstrual women. The medications now used to treat PMDD include ibuprofen (Advil, Motrin, Midol Cramp), ketoprofen (Orudis KT), naproxen (Aleve), or aspirin (National Women’s Health Center, 2010).

Endometriosis

Sometimes tissue resembling the inner lining of the uterus (the endometrium) is found outside the uterus. This condition is known as endometriosis. Endometriosis is found most often on the lining of the pelvic cavity, the ovaries, the rectum, and the colon, and in the uterus and on the bladder. Sometimes it is also found on the small intestine, liver, spleen, and lymph nodes. Endometriosis is, unfortunately, not an uncommon occurrence. In fact, it affects 63 million women and girls in the United States, 1 million in Canada, and millions more worldwide (Endometriosis Association, 2010). Although it can affect all women, endometriosis is most common among 25-to 30-year-olds, and it has also occurred in girls as young as 11 years of age.

The causes of endometriosis are not known, although there are several theories. One theory holds that pieces of the endometrium somehow find themselves in the fallopian tubes and are transported into the pelvic cavity. This is called retrograde menstruation. The endometrium pieces then adhere to one another to form adhesions, which cause pain. Another theory is based on the realization that in the early stages of fetal development there are but a few cells present and that these cells eventually differentiate into different tissue. This theory posits that perhaps cells outside the uterus, for some unknown reason, take on the function of cells in the endometrium. Still another theory argues that endometrial cells are transported through the bloodstream or through the lymph system to sites elsewhere in the body. Finally, some researchers believe that endometriosis is caused by a breakdown in the function of the immune system, resulting in an inability to destroy endometrium cells that manage to leave the uterus.

Women who acquire endometriosis usually experience a great deal of pelvic pain. This pain most often occurs just before or during menstrual bleeding, and usually abates after bleeding ceases. Pain may also be experienced in the lower back or lower abdomen and may be associated with urination. Fatigue and/or bloated feelings may occur, there may be blood in the urine and/or heavy menstrual bleeding, and diarrhea or constipation may result. In addition to causing these uncomfortable symptoms, endometriosis can lead to serious health consequences. For example, scar tissue can form and result in infertility. Or, adhesions can connect organs such as the uterus, fallopian tubes, ovaries, and intestines.

 Ethical DIMENSIONS: Should PMS Be Used as an Excuse for Socially Unacceptable Behaviors?

In 1980 and 1981, in two separate trials, British courts set free two women who admitted to murder because they were judged to suffer from PMS. In the first case, a barmaid, Sandie Smith, stabbed another barmaid during a fight. Testimony proved Smith had a history of violent outbursts that, when subsequently treated, were controlled with injections of progesterone. In the other case, Christine English purposely drove her car into her lover after an argument. English, too, was able to prove that she suffered from PMS and that she had menstruated a few hours after the murder. Both women were judged to have “diminished responsibility” and had their charges reduced to manslaughter. They were then released contingently on their getting treatment for their PMS.

Some people believe that PMS is so unsettling a condition that the physical discomfort and the emotional changes can understandably make a woman irritable, angry, hostile, and prone to do things she might not otherwise do. Given an incident to provoke such a reaction, even violent acts can be performed without the woman’s really being responsible for them. These women should be encouraged to seek treatment for their illness rather than be regarded as criminals. They should be treated with compassion rather than imprisoned. Advocates of this position would contend that these women are not in control of their decisions and should, therefore, be excused for their actions.

Others argue that murder is never excusable. If women are allowed to offer PMS as a defense, then any ill person can use a similar defense. That would allow antisocial behavior to occur without any punishment or societal sanctions. Anarchy would result. Women, or other sick people, could (short of committing murder) sign contracts and not be held responsible for them, could steal items from stores and not be prosecuted for that theft, and could even sexually abuse children without fear of reprisal. Opponents of this PMS defense conceive of an unmanageable situation if PMS sufferers, or any other group of ill people, are not held accountable for their actions.

If you were a judge, would you rule that “diminished responsibility” was a justifiable defense for women who experienced PMS? What other behaviors would you allow to be excused by PMS? What other physical or emotional conditions would you allow to be similarly used to explain people’s actions?

Endometriosis is treated in several ways, depending on the severity of the symptoms and the location of the tissue. Laparoscopic surgery—in which two small incisions are made in the abdomen through which is inserted a viewing instrument to perform the surgical cut—can be helpful in identifying the existence of endometrial tissue outside the uterus and determining its location. Then the tissue can be surgically removed before the procedure is completed. Sometimes the tissue has spread so extensively that the surgeon needs to open the abdomen to remove it rather than merely inserting a laparoscope. This procedure is called a laparotomy.

In addition to surgery, there are medications that result in lower levels of estrogen than normal and, therefore, alleviate much of the pain associated with endometriosis. Some of these drugs are synthetic hormones that stop the ovaries from producing estrogen, causing cessation of menstruation. These are known as gonadotropin-releasing hormone analogues (GnRH analogues). Another drug sometimes used is a synthetic hormone derived from testosterone (Danazol). More frequently, oral contraceptives are prescribed to prevent ovulation and reduce (when estrogen and progestin are used in combination) or eliminate menstrual bleeding. Finally, relief from pain may be obtained temporarily with ibuprofen or other analgesics (pain relievers).

Myth vs Fact

Myth: The menstrual cycle is 28 days long and does not fluctuate in length for any one woman.

Fact: The most prevalent menstrual cycle happens to be 30 days long. Even so, the cycle varies greatly from woman to woman and even for any one woman.

Myth: Women are usually emotionally “low” premenstrually and emotionally “high” at ovulation.

Fact: This has not been conclusively determined. There are conflicting research findings and criticism of the methodology researchers have employed to answer this question.

Myth: Women’s work activity needs to be adjusted during their periods.

Fact: Though this myth has been used to support job discrimination practices against women, there is no evidence that women cannot function normally in their jobs when menstruating.

Myth: Women should not swim or exercise as usual during their periods.

Fact: With the usual hygienic practices used by women, there are no known physical reasons for not exercising as usual. For some women, iron supplementation may be necessitated by the iron lost in the menstrual blood, but that precaution is a simple one.

Myth: Women’s sexual desire is at a peak just before and just after menstruation.

Fact: For some women and for some cycles this may be true. However, sexual desire involves more than one’s physical condition—the nature of the relationship, the setting, one’s comfort with sexuality, one’s health, and so on—so that expecting sexual desire to be determined solely by the menstrual cycle is unrealistic.

The Menstrual Cycle and Sex

Many researchers have searched for a relationship between sexual interest and the time of the menstrual cycle. Findings of these studies have, for the most part, been contradictory (Bullivant et al., 2004). Some researchers report that women are more interested in sex just before menstruation (AskMen, 2011), and others find them most interested during menstruation (Friedman et al., 1980). Still others report the middle of the menstrual cycle to be the most sexually active (Adams, Gold, & Burt, 1978) or the time just after the menses to be when most sexual fantasizing occurs (Matteo & Rissman, 1984). Several other studies have not found the midcycle related in any way to heightened sexual arousal (Slob et al., 1991; van Goozen et al., 1997).

When are women most sexually aroused? The answer to this question probably varies from one woman to another and, in addition to menstrual physiology, depends on such factors as one’s lover, the setting, and numerous psychosocial factors such as the woman’s comfort with her body, her level of self-esteem, and her religious and cultural beliefs regarding menstruation. The bottom line is that women can be sexually aroused at any time during their menstrual cycle (menstruation.com.au, 2008).

 Did You Know . . .

If a couple decides to engage in sexual intercourse when the woman is menstruating, they should realize that transmission of HIV is probably more likely at this time of the menstrual cycle than at any other. That is because of the blood present and the probability that some of that blood will have contact with an opening (albeit microscopic) into the body. If HIV is in that blood, it can infect the sexual partner. The “safer sex” practice of refraining from sexual intercourse while a woman is menstruating is usually overlooked. From the woman’s perspective, participating in coitus while menstruating can facilitate HIV entry into her body.

Although there are no medical reasons to refrain from coitus during menstruation (if one or both partners are HIV-negative, see the Did You Know box on this page), many couples do so. At least one study found over half the men and women surveyed believed couples should not engage in sexual intercourse when the woman is menstruating (Research Forecasts, 1981). According to a 1996 study, 16 percent of women 20 to 37 years of age reported that they had had sexual intercourse during their last menstrual period (Tanfer & Aral, 1996). Some people refrain from coitus during menstruation because of religious taboos. For example, in Orthodox Judaism menstruating women are considered unclean and are supposed to sleep in a separate bed. When they are through menstruating, Jewish women are supposed to cleanse themselves in a ritual bath called a mikvah. Others refrain from sexual intercourse during menstruation because of the potential messiness. Still others refrain because of the physical discomfort they feel—bloating, cramping, or fatigue. And, finally, there are women who are ashamed of their menstrual flow and prefer to keep it a private matter not shared with anyone. A couple who refrains from sexual intercourse during menstruation should be comfortable with their decision, whatever the reason; likewise, a couple who decides to engage in coitus during this time should be comfortable with their decision.

A couple who decide to engage in sexual intercourse during the menstrual period can take several actions to make that experience as enjoyable as possible. First, they should discuss any concerns they may have—for example, the potential messiness or any religious inhibitions. Second, the woman can wear a diaphragm or cervical cap to hold back the menstrual flow. Because the menstrual fluid can sometimes irritate the penis, the man should wear a condom (a good idea anytime coitus occurs). With these simple actions, coitus during menstruation can be a positive and rewarding experience.

 Menopause

Usually between the ages of 40 and 55 years, women produce progressively less estrogen and progesterone, as an effect of aging on the ovaries. Whereas the pituitary continues to produce FSH and LH, the ovaries can no longer respond to these pituitary hormones as they once could. This decrease in estrogen and progesterone occurs over approximately a 5- to 10-year period and results in a cessation of menstruation. The period when these changes take place is called the perimenopause, or the climacteric; when menstruation has not occurred for a year, we call that menopause.

perimenopause (climacteric)

The period just before menopause when the production of estrogen and progesterone is decreasing, usually a 5- to 10-year period.

menopause

The time when a woman’s menstrual cycle ceases, usually between 40 and 55 years of age.

 Sexually Related Diseases: Self-Care and Prevention

Some diseases are not transmitted by sexual activity but do affect sexual organs. These are termed sexually related diseases (SRDs). Advances in chemical and surgical treatment of diseases of the sex organs have improved 5- and 10-year survival rates and made restoration of function more attainable than ever before. Maintaining reproductive health means following safer sexual practices, paying attention to your body, monitoring it for certain signs, using the specialized health services available, and seeking information—from organizations and publications—on issues related to reproductive health. Successful treatment of SRDs generally depends on early diagnosis of potential problems.

The Female Reproductive System

Self-care and disease prevention activities for the female involve many of the sexual organs, including the breasts, cervix, uterus, ovaries, and vagina.

The Breasts

The most common breast disorders are cancer, cystic mastitis (mammary dysplasia), fibroadenoma, nipple discharge, and breast abscess. Most of these disorders occur only in women, but men are susceptible to breast cancer, too.

Breast Cancer

The breast is the leading site of cancer in American women and the second major cause of cancer death (the first is lung cancer). At the time of this writing, it is estimated that 207,080 new cases of breast cancer will have been diagnosed in women in 2010, and 1,970 cases will have been diagnosed in men (American Cancer Society, 2010a). After increasing about 4% per year in the 1980s, breast cancer incidence rates have dropped slightly. Still, 39,840 women and 390 men will probably have died of breast cancer in 2010. And yet, death rates from breast cancer continue to decline, especially among younger women. The 5-year survival rate for localized breast cancer increased from 72% in the 1940s to 98% in 2010. If the cancer has spread regionally, however, the 5-year survival rate drops to 84%, and, if the cancer has spread to distant locations (metastasized), the survival rate drops to 23%. Eighty-two percent of women diagnosed with breast cancer survive 10 years, and 90% survive 5 years.

breast cancer

The most common type of cancer in women.

No specific cause of breast cancer is known, but epidemiological studies have identified certain risk factors that predispose women to breast cancer. One of these risk factors is age. As women get older, the risk increases. The risk is also higher in women who have a family history of breast cancer, who experienced an early menarche or a late menopause, who recently used oral contraceptives or postmenopausal estrogens, and who never had children or had the first live birth at a late age. Other suspected risk factors are a diet high in fat, although a large-scale 1999 study calls this relationship into question (Holmes et al., 1999); exposure to pesticides and other selected chemicals; alcohol consumption; weight gain; and physical inactivity. In addition, two new genes that appear to make women susceptible to breast cancer have been discovered, BRCA1 and BRCA2. However, only 5% to 10% of breast cancers are thought to be inherited, and only 5% of breast cancer patients were found to have the gene BRCA1 or BRCA2. One study found that 75% of women in whom breast cancer develops have no identifiable risk factor other than gender and age (Hortobagyi, McLelland, & Reed, 1990). This makes it especially important for all women to learn breast self-examination and to have regular breast examinations by a physician.

Breast self-examination (BSE) is a self-care procedure women can adopt. Although medical specialists actively check for breast cancer in routine examinations, some experts believe that checking one’s own breasts every menstrual cycle increases the chances of early detection. The technique is simple. If cancer is present, the earlier it is diagnosed, the better the chance for survival.

breast self-examination (BSE)

A periodic self-care procedure that involves feeling the breast for any abnormalities. The test is performed once every menstrual cycle or every month after menopause.

In April 1987 a committee of the United States Public Health Service (which had been established to recommend those medical procedures with demonstrated effectiveness and those without) caused concern among cancer prevention specialists by citing BSE as a procedure whose value had not been clearly shown. The committee was charged with reviewing the scientific evidence for many medical screenings and examination procedures and eliminating those that contributed to the increasing cost of health care. As such they decided that BSE was not employed by enough women and cancers not found in enough quantity to warrant public health campaigns to encourage women to perform the examination. Other cancer experts, who argued that BSE does not cost a woman any money and that it can uncover early treatable cancers, recommended that women ignore the committee’s finding and continue doing monthly BSEs. Canadians have also weighed in on this issue. The Canadian Task Force on Preventive Health Care (Baxter, 2001) studied the benefits and harms associated with breast self-examinations and found no evidence of effectiveness and evidence of harm. The harm included an increase in the number of physician visits for the evaluation of benign breast lesions and significantly higher rates of benign breast biopsy findings. As a result, the Canadian Task Force recommended that women not perform breast self-examinations. The American Cancer Society (2007a) takes a neutral stance, stating in their guidelines that breast self-exam is an option for women starting in their 20s. More recently, after conducting an extensive review of the research literature, the U.S. Preventive Services Task Force (2009) concluded there were more risks than benefits associated with breast self-exams and, therefore, recommended against teaching women how to perform breast self-examination.

It is recommended by several organizations that women older than age 40 get a mammogram annually. Younger women should have annual clinical breast exams every 3 years.

If choosing to perform BSE, for best results, perform the exam when the skin is wet or moist—after showering or after applying body lotion. Menstruating women should perform this test 1 week after their period; postmenopausal women should check their breasts at least once a month. All women should check their breasts visually in the mirror and by means of this exam. Consult a gynecologist if you find a lump, a thickening, or any other unusual feature. These symptoms may include pain in the breast, discharge from the nipple, a change in the character of the nipple itself, or changes in the character of the breast.

In addition, the American Cancer Society, the American Medical Association, and the National Comprehensive Cancer Network recommend that women have regular breast examinations by a physician. These examinations include both clinical breast exams and mammography screening, depending on a woman’s age and medical history. A clinical breast exam is similar to BSE, except that it is conducted by a physician trained to detect any abnormalities. It is suggested that women aged 20 years and older have a clinical breast examination regularly, preferably every 3 years between ages 20 and 40 years and annually thereafter. However, the U.S. Preventive Services Task Force also questioned the value of clinical breast exams (2009).

clinical breast exam

A breast examination conducted by a physician to detect any abnormalities.

mammography

An X ray of the breasts to detect any abnormality before it is visible or palpable.

 Gender DIMENSIONS: Breast Self-Examination

By regularly examining her own breasts, a woman may notice any changes that occur. The best time for breast self-examination (BSE) is about a week after your period ends, when your breasts are not tender or swollen. If you are not having regular periods, do BSE on the same day every month.

• 1. Lie down with a pillow under your right shoulder and place your right arm behind your head.

• 2. Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast.

• 3. Press firmly enough to know how your breast feels. A firm ridge in the lower curve of each breast is normal. If you are not sure how hard to press, talk with your doctor or nurse.

• 4. Move around the breast in a circular, up-and-down line, or wedge pattern (a, b, c). Be sure to do it the same way every time, check the entire breast area, and remember how your breast feels from month to month.

• 5. Repeat the exam on your left breast, using the finger pads of the right hand. (Move the pillow to below your left shoulder.)

• 6. If you find any changes, see your doctor right away.

• 7. Repeat the examination of both breasts while standing, with one arm behind your head. The upright position makes it easier to check the upper and outer part of the breasts (toward your armpit). This is where about half of breast cancers are found. You may want to do the standing part of the BSE while you are in the shower. Some breast changes can be felt more easily when your skin is wet and soapy.

For added safety, you can check your breasts for any dimpling of the skin, changes in the nipple, redness, or swelling while standing in front of a mirror right after your BSE each month.

Mammography is also recommended. A mammogram is an X ray of the breast that often allows physicians to detect breast lumps before they would be palpable by a physician (see Figure 4.11). Some organizations argue that women older than age 40 years should have a mammogram annually. However, whether women in their 40s or women over 74 years old receive benefit from mammograms has been called into question by the U.S. Preventive Services Task Force (2009). (See Table 4.3.) The Centers for Disease Control and Prevention (2008) reported that in 2008, 76% of women aged 40 years and older had had a mammogram within the previous 2 years. Obviously, we have a long way to go in educating women about the need to get mammograms and the benefits they can expect.

FIGURE 4.11 The sizes of breast masses detectable by mammography, physical examination, and self-examination illustrate the importance of screening mammography in the early detection of breast cancer.

There is increasing interest in using breast magnetic resonance imaging (MRI) as a screening test for breast cancer. The use of MRI to detect breast cancer is being studied at the time of this writing. Some studies have shown that MRI is associated with higher falsepositive rates. Thus women who are screened with MRI may have more unnecessary surgical biopsies. At the present time, it is still undetermined whether the increase in cancer detection achieved with MRI, in conjunction with the as-yet-undemonstrated decrease in death rates as a result, conveys enough of a benefit to warrant recommendations for wider use of this technology, given the large increase in false-positive rates and the possibility of overdiagnosis (National Cancer Institute, 2008a).

When breast cancer is suspected, a biopsy is performed. In a needle biopsy a fine needle is inserted into the tumor and fluid or cells are withdrawn. If the lump dissipates as soon as fluid is obtained, the lump is confirmed as a cyst and generally no further procedure is needed. An open biopsy is a minor surgical procedure during which tissue of the tumor is removed and examined for possible cancer (carcinoma).

biopsy (open biopsy)

Usually referred to as an open biopsy, a minor surgical procedure during which tissue of a tumor is removed and examined for presence of cancer.

needle biopsy

Insertion of a needle into a lump in a breast to see whether fluid (which indicates a cyst rather than a tumor) can be removed.

carcinoma

A type of cancer emanating from epithelial cells.

Patients who have breast cancer are classified in terms of stages. These stages are determined by the characteristics of the tumor and the lymph nodes and whether metastasis—spread of the cancer to other body sites—has occurred. Treatment naturally depends on the stage of the cancer. The treatment of breast cancer may involve lumpectomy, in which only the breast lump and lymph nodes under the arm are removed, usually followed by radiation therapy; mastectomy, in which the breast and lymph nodes under the arm are removed; chemotherapy, treatment with drugs; radiation therapy; and hormone therapy. There are three kinds of mastectomy: simple mastectomy, in which the whole breast is removed, sometimes along with lymph nodes under the arm; modified radical mastectomy, the most common form of mastectomy, in which the breast, many of the lymph nodes under the arm, the lining over the chest muscles, and sometimes part of the chest wall are removed; and radical mastectomy (also called the Halstead radical mastectomy), in which the breast, chest muscles, and all lymph nodes under the arm are removed. Radical mastectomy used to be the most frequently performed operation for breast cancer but now is used only when the tumor has spread to the chest muscles.

metastasis

Spread of cancer from a primary site to other parts of the body.

lumpectomy

Removal of a lesion, benign or malignant.

mastectomy

Removal of the breast and/or other tissue. Simple: Removal of only the breast (sometimes with removal of lymph nodes under the arm). Modified radical: Removal of the breast, lymph nodes, lining of the chest muscle, and sometimes part of the chest wall. Radical: Removal of the breast, lymph nodes, and chest muscle.

chemotherapy

Use of chemicals (medication) to treat disease; may be oral, intravenous, intramuscular, or topical.

radiation therapy

A form of treatment for cancer that uses carefully directed radiation to destroy cancer cells.

hormone therapy

Form of treatment for cancer that uses hormones to combat cancer cell growth.

TABLE 4.3 Breast Cancer Screening Controversy

Source: Data from U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 151 (2009), 716–726.

For patients with no lymph node involvement, hormone therapy may be prescribed as a preventive measure against recurrence of cancer. The most commonly used hormones are tamoxifen and special “designer estrogens,” which may be administered for 5 years. There presently remains a question regarding the increased risk of development of cancer of the uterus for women on hormonal therapy. For early-stage breast cancer, long-term survival rates after lumpectomy plus radiation therapy are similar to survival rates after modified radical mastectomy, and, therefore, this less invasive procedure is being used more often—except for those women who choose not to experience the side effects of radiation and thus choose mastectomy.

We live in a society in which breast size and shape are mistakenly seen as contributing greatly to a woman’s sexuality. Thus a woman who loses a breast through amputation can be devastated. Many women who have had mastectomies, whether or not they are sexually active, suffer feelings of loss, fear of rejection, and, of course, fear of the cancer’s recurrence. Community support systems such as the Reach to Recovery Project of the American Cancer Society (ACS) and the Breast Referral Service, founded by Rose Kushner, who herself recovered from a mastectomy, give invaluable support to women in adjusting to the treatment of their cancers. The involvement of lovers or husbands and children is of great importance, because all of them, not just the woman, must adjust to her changed appearance and emotional sensitivity. Breast reconstruction after a mastectomy is also available. It offers a woman a more normal appearance and often eases her acceptance of the change in her body. This option should be discussed with the surgeon before breast surgery, if possible.

 Multicultural DIMENSIONS: Breast Cancer More Deadly in African Americans

Although breast cancer develops more often in white women, African American women are more likely to die of it (American Cancer Society, 2010a). Researchers and epidemiologists have been perplexed as to why. It was originally assumed that this difference was due to the disproportionately high number of African American women who live in poverty, resulting in lack of access to health care. That, in turn, would lead to later diagnosis and, consequently, less effective treatment. However, having studied this dilemma for several years, scientists have concluded that, although poverty status plays a role (it is estimated that poverty accounts for approximately 50% of the cause), biology is significantly involved. Tumors in African American women are just more virulent.

Evidence for this conclusion can be found in a study that compared African American and white women who belonged to health maintenance organizations (HMOs) in which health care was readily available (access to mammograms and other medical care). Still, the African American women HMO members had larger and more advanced tumors when diagnosed. The suspicion was that these tumors grew faster, and that is why at the time of diagnosis they were larger and more advanced.

Research also indicates that African American women do not wait any longer to seek medical diagnosis when identifying a breast abnormality than do white women. Consequently, that is not a significant variable in the difference in tumor size or death rates between African American and white women.

A review of research of breast cancer in African American women published in the New York Times (Kolata, 1994) summarized what is known about this situation. Cited are several studies in which tumors in African American women were found to be more actively dividing than those in white women, and more lacked hormone receptors and had tissue features indicative of unfavorable diagnosis.

Although it is wise for all women to obtain regular medical examinations, given what we know about tumors in African American women, it is particularly prudent for them to do so.

Reconstructive breast surgery can create a breastlike structure by using saline (salt) water encased in a silicone pouch that is implanted under a woman’s skin and chest muscle.

Cystic Mastitis

Also called chronic cystic mastitis, fibrocystic condition, and mammary dysplasia (cell change), cystic mastitis is the most common breast condition. It is usually found in women 40 to 60 years of age (California Pacific Medical Center, 2008). Because cystic mastitis is uncommon in postmenopausal women, it is believed to be related to estrogen activity. In cystic mastitis small and large cysts form in the breast tissues. The cysts are generally filled with fluid and may have to be drained frequently. Sometimes the cysts must be removed. Studies have concluded that “fibrocystic breasts” occur frequently in women and are not associated with significant increases in risk for breast cancer (Mayo Clinic Staff, 2010). One research report indicated a possible link between cystic mastitis and coffee, tea, cola, and chocolate consumption. On the basis of this study, some practitioners recommend that women decrease or eliminate the consumption of these products. But because this treatment approach has not been tested by using randomized double-blind studies, medical researchers and practitioners have questioned its validity.

cystic mastitis

Known also as fibrocystic disease, a condition characterized by fluid-filled lesions (cysts) that are tender and believed to be related to estrogen activity.

Fibroadenoma

Fibroadenoma is a benign (noncancerous) tumor that may develop in white women in their early 30s and in black women somewhat earlier (there are no data on other groups). The tumor is usually firm, round, and somewhat movable. Generally the treatment is surgical removal.

fibroadenoma

A benign (noncancerous) tumor that is firm, round, and somewhat movable.

Nipple Discharge

A discharge from the nipples of women who are not nursing can be due to cystic mastitis, to a small benign tumor (called a papilloma) in a duct leading to the nipple, or to an uncommon condition (ectasia) in which the ducts of the breast enlarge and distend, allowing fluid to accumulate and escape. Occasionally the use of hormones—such as oral contraceptives and postmenopausal estrogen supplements—can cause nipple discharge, which should cease when the drugs are discontinued. Any discharge from the nipples should be checked by a physician.

Breast Abscess

Generally breast abscesses (infections) are seen in nursing women, but they occur in non-nursing women as well, and in either case should be treated by a physician. Redness, swelling, or a tender, painful mass is symptomatic of breast infection. If the infection is not stopped, an abscess can develop. These are usually treated by incision and drainage, antibiotics, or both.

breast abscess

Infection of the breast characterized by redness, swelling, and a painful or tender mass.

The Cervix

Rates of invasive cervical cancer, which involves deep-tissue layers of the cervix and sometimes spreads to other organs, have decreased steadily over the past several decades. This decline is attributed to the increase in Pap smear screening, which leads to early detection and subsequent early treatment. Still, an estimated 12,200 cases of invasive cervical cancer were diagnosed in 2010 with 4,210 deaths (American Cancer Society, 2010a), in spite of a steady decline in death rate from cervical cancer since 1982. Cervical cancer death rates declined for African Americans more rapidly than for whites. However, in 2010 the mortality rate for African American women (4.6 per 100,000) was twice as high as it was for white women (2.2 per 100,000). The 5-year relative survival rate for the earliest stage of invasive cervical cancer is 92%. The overall (all stages combined) 5-year survival rate for cervical cancer is about 71% (American Cancer Society, 2010a).

invasive cervical cancer

Cancer that has invaded a wide area of cervical tissue.

Although the exact cause of cervical cancer is unknown, several factors can put you at risk. Among these are having your first intercourse at an early age, having multiple sex partners, having many pregnancies, having a mother who took diethylstilbestrol (DES) while pregnant with you, and having a sexually transmitted infection caused by the human papillomavirus (HPV).

The American Cancer Society (2010b) recommends a Pap smear be performed annually with a pelvic exam in women who are, or have been, sexually active or who have reached the age of 18 years. After three consecutive annual exams have normal findings, the Pap test may be performed less frequently at the discretion of the woman and her physician. Pap smear screening is a simple procedure that involves swabbing a small sample of cells from the cervix, transferring these cells to a slide, and examining them under a microscope. Regular gynecological screening is advised for all women, particularly because early cell changes in the cervical tissue do not present symptoms a woman can recognize herself—although invasive cervical cancer sometimes does cause a bloody discharge between periods and/or bloody spotting after intercourse. Unfortunately, data indicate that not enough women are getting regular Pap tests. In 2008, only 75% of women had a Pap smear within the past 3 years (National Center for Health Statistics, 2009).

Pap smear

A test of the tissue of the cervix for cervical cancer (named after its founder, Dr. Papanicolaou).

Other procedures have been developed to screen for cervical cancer. One of these is called PapSure (Redfran, 2002). This procedure involves a visual inspection of the cervix using a scope and a blue chemical light, and is performed in conjunction with a traditional Pap smear. Another cervical cancer detection test is the experimental LUMA Cervical Imaging System (McMillan, 2004). In this procedure, the cancerous tissue absorbs light differently than healthy tissue, showing possible problematic areas. Certainly, even more advanced screening techniques will be developed in the coming years.

Treatment for invasive cervical cancer generally consists of surgery and radiation, or both. Ninety percent of patients survive 1 year after diagnosis, and 73% survive 5 years. When detected at an early stage, invasive cervical cancer is one of the most successfully treated cancers, with a 5-year survival rate of 92% for cancers that have not spread. Unfortunately, only 57% of invasive cervical cancer in white women and only 49% in African American women are diagnosed at this stage. Again, this points to the value of getting a Pap test regularly (American Cancer Society, 2008).

At the time of this writing, it was estimated that 43,470 cases of cancer of the uterus, most often of the endometrium, would be diagnosed in 2010. Incidence rates of uterine cancer have varied since the mid-1980s. In 2006, the incidence rate for white women was 24.3 per 100,000, and 17.5 per 100,000 for African American women (National Center for Health Statistics, 2010). Although incidence rates are higher among white women than African American women, the relationship is reversed for mortality rates: African American women have mortality rates that are nearly twice as high as rates among white women.

Estrogen is the major risk factor for uterine cancer. Women who choose estrogen replacement therapy to combat the effects of menopause, who are administered tamoxifen to prevent breast cancer or its recurrence, who experience an early menarche, who have a late menopause, who never have children, or who do not ovulate have been shown to be at increased risk. Conversely, pregnancy and the use of oral contraceptives appear to provide protection against uterine cancer.

The Pap test is rarely effective in detecting uterine cancer early. It is with this realization that the American Cancer Society recommends that women older than 40 years have an annual pelvic exam and that women at high risk have an endometrial biopsy at menopause and periodically thereafter. Early warning signs include uterine bleeding or spotting; pain is a later symptom. Treatment, which depends on the stage of the cancer, consists of surgical removal of the uterus and/or ovaries, radiation therapy, hormonal therapy, and chemotherapy. The 5-year survival rate is 96% if the cancer is discovered at an early stage, when it is contained regionally. Survival rates for whites exceed that for African Americans.

The Ovaries

Ovarian cysts and tumors can occur when a female is any age. A cyst is an abnormal cavity that is filled with fluid. The most common ones are called functional cysts; these occur on the follicle or corpus luteum and are usually caused by the failure of the follicle to rupture and discharge the egg. Generally they are small and not particularly significant. They usually disappear spontaneously within a month or two.

functional cyst

An ovarian cyst that occurs on the follicle or corpus luteum, usually caused by the failure of the follicle to rupture and release an egg.

Dermoid cysts are common in young women. They contain hard, fatty material, and sometimes remnants of teeth. These are believed to be embryonic in nature and are considered benign. Most ovarian cysts and tumors are usually benign, but if they cause symptoms such as pain, tenderness, and internal bleeding, they can require surgery. Because there is always the possibility of future problems, such as malignancy, a woman should remain under medical supervision once cysts or tumors have been diagnosed.

dermoid cyst

A type of benign ovarian cyst commonly found in young women.

In the Stein–Leventhal syndrome the ovaries become enlarged and have cysts on them. Infertility and secondary amenorrhea also result. This condition affects one in ten women of childbearing age and is the most common cause of female infertility. Although its causes are not specifically known, genes are thought to be one factor because women experiencing this condition tend to have a mother or sister with it as well. Researchers also think insulin could be a cause given that Stein–Leventhal syndrome affects the ovaries and ovulation (The National Women’s Health Information Center, 2010). Symptoms include infrequent menstrual periods, no menstrual periods, and/or irregular bleeding; infertility; increased hair growth on the face, chest, stomach, back, thumbs, or toes; and pelvic pain. Treatment may include birth control pills; medications such as Clomid and Serophene to stimulate ovulation; surgery (“ovarian drilling”) that involves puncturing the ovary and administers an electrical current to destroy a small portion of the ovary; and lifestyle changes (eating a healthy diet, exercise, and weight loss) to improve the body’s use of insulin. Most patients respond to therapy, and frequently fertility is restored to normal.

Stein–Leventhal syndrome

Reproductive malfunction in women; a syndrome of endocrine origin that involves ovarian cysts, amenorrhea, and infertility.

Ovarian cancer killed an estimated 13,850 American women in 2010. In fact, ovarian cancer causes more deaths than any other cancer of the female reproductive system. An estimated 21,880 new cases of ovarian cancer were diagnosed in 2010. One of the reasons ovarian cancer is so deadly is that its symptoms are “silent”: They may go unnoticed until late in development. Rarely does abdominal swelling occur and even more rarely abnormal vaginal bleeding. Stomach gas, discomfort, and distention that cannot be explained by other causes may indicate a need to have a thorough medical examination with ovarian cancer in mind.

ovarian cancer

Cancer of the ovaries; it causes more cancer deaths than any other cancer of the female reproductive system.

Risk factors include never having children, being older (ovarian cancer occurs more frequently in women in their 80s), and having had certain other cancers such as colon and endometrial cancers. As with all cancers, early detection is important. Pelvic exams are most valuable, because Pap tests rarely are effective in uncovering ovarian cancer. In 2000 a new technique using sonography was developed that has the potential of diagnosing ovarian cancer earlier than is presently possible. This new method, transvaginal ultrasonography, was able to diagnose stage 1 ovarian cancer in 59% of women, whereas other methods could detect only 30% of these stage 1 cancers (Sato et al., 2000). Treatment can include surgical removal of one or both of the ovaries and/or the fallopian tubes (called a salpingo-oophorectomy) and the uterus (hysterectomy). If disease is detected early and the tumor is small, only the involved ovary is removed. This consideration is especially important to young women who want to have children. Radiation therapy and chemotherapy are also used in the treatment of ovarian cancer. The 5-year survival rate varies by the stage when diagnosed. If cancer is diagnosed and treated early, the survival rate goes up to 94%. Unfortunately, only 15% of cases are detected in their localized stage. Five-year survival rates vary from 28% to 94%, depending on the stage of the cancer.

Sexual health begins with routine self-exams.

The Vagina

Normal vaginal secretions are odorless, and the acidity of the vagina helps it to cleanse itself. Nevertheless, some women choose to cleanse the vagina by douching—that is, by rinsing with water or a vinegar and water solution. A vaginal douche, the value of which has been questioned, is not recommended and can be harmful if not done correctly. Damage can occur in two main ways: (1) Improper insertion of the douching material may actually damage the tissue, resulting in an increased chance of infection; (2) the chemical balance of the vagina can be altered, affecting contraceptive function. For instance, if a woman is using a spermicidal cream or other form of spermicide as a means of contraception, douching may destroy its effectiveness.

douche

Cleansing of the vagina by inserting a nozzle that secretes a recommended cleansing substance, a controversial procedure.

Smegma, a cheeselike substance secreted by the glans penis of males, may have effects on women’s health. A female engaging in coitus with a male who has not washed away smegma could be subjecting herself to vaginal infections. There is also some concern that smegma may contribute to cancer of the cervix. It seems prudent, therefore, for sexually active women to make sure that their male sexual partners engage in the routine hygiene care necessary to remove smegma. Although it may be embarrassing, this may be a small price to pay for the prevention of vaginal infection and cervical cancer. Signs of sexually transmitted infections should also be given attention. Make sure to check your vulva routinely. See a healthcare provider if you have unusual discharges, abdominal pain, or open sores on your genitalia.

Toxic Shock Syndrome (TSS)

In the late 1970s several young women died of a previously little-known disease called toxic shock syndrome (TSS). The toxins that cause this syndrome are produced by the Staphylococcus aureus bacteria, which may grow in the vagina and are absorbed by the body. These toxins enter the bloodstream and cause high fever (above 102°F), nausea, vomiting, diarrhea, a rapid drop in blood pressure, and sometimes aching muscles and peeling skin on the palms and feet. The exact mechanism of transmission is unknown. The syndrome appears to be linked to the use of tampons—particularly those made of super-absorbent material. It is thought that the presence of the tampon in the vagina for a prolonged period (6 hours or more) may provide an environment conducive to proliferation of the toxin-producing bacteria. When some tampons are inserted into the vagina, small irritations of the vaginal mucosa may occur and promote entry of the bacteria.

toxic shock syndrome (TSS)

A syndrome caused by Staphylococcus aureus bacteria in which symptoms include high fever, nausea, vomiting, diarrhea, and a drop in blood pressure; a potentially fatal syndrome that has been linked with the use of superabsorbent tampons.

It is recommended that superabsorbent tampons not be used because they pack the vagina tightly, prevent air circulation, and allow bacteria to proliferate. It has also been suggested that women using other types of tampons leave them in place for no longer than 2 hours and not use them at all during the night while sleeping.

Toxic shock syndrome has been seen in both genders among postsurgical patients, burn victims, and patients with boils and abscesses. Nonmenstrual cases constitute about half of all reported cases (Nemours Foundation, 2007).

Care from Medical Specialists

All health-related specialists agree that you should report any unusual signs or symptoms related to the reproductive system to a specialist in women’s reproductive health—a gynecologist or a gynecological nurse practitioner. Furthermore, the American College of Obstetrics and Gynecology recommends that women have a routine gynecological exam every year, even when no signs or symptoms appear. Routine checkups, usually conducted on a special table with the woman’s knees up and her feet in stirrups, consist of the following procedures:

gynecologist

A physician specializing in women’s reproductive health.

• 1. An inspection of the external genitals for any irritations, discolorations, unusual discharges, or other abnormalities.

• 2. An internal check for cystoceles (bulges of the bladder into the vagina) and rectoceles (bulges of the rectum into the vagina). The examiner also looks for pus in the Skene’s glands and for the strength of the pelvic and abdominal muscles. He or she also tests urine control by asking the patient to cough while checking to see whether urine flows involuntarily.

• 3. An inspection of the vagina and cervix by means of a speculum, a plastic or metal instrument that is inserted into the vagina to hold the walls apart during the examination (Figure 4.12). (At this point and throughout the remainder of the examination, if you are interested in seeing your genitals and watching the exam, ask the examiner to set up a mirror for you and to point out the various organs. If the examiner is not sympathetic to this request, you might consider looking for another practitioner.) The examiner will look for anything unusual, such as lesions (sores) or inflammation affecting the vagina or cervix. Next the practitioner will scrape a tiny amount of tissue from the cervix by using a small wooden instrument called a spatula. This tissue will be used for the Pap smear. If requested by the patient, the smear can also be tested for signs of gonorrhea.

speculum

A metal (or plastic) instrument that is inserted into the vagina to hold the walls apart, allowing for medical examination.

FIGURE 4.12 Medical examination with speculum and spatula in place.

• 4. A bimanual examination (Figure 4.13). By sliding the index and middle fingers of one hand into the vagina and pressing down on the abdominal wall from the outside, the examiner feels for the uterus, fallopian tubes, and ovaries to determine their position, their size, and the presence of pain or inflammation. The examiner may also examine the internal genitals by inserting one finger into the rectum and another into the vagina.

Speculum and spatula.

• 5. An examination of the breasts for lumps or thickenings.

Two additional points should be noted about the routine gynecological exam. First, although the checkup may be uncomfortable, it should not be painful. Second, before beginning the physical examination, the practitioner should take a gynecological history. Noted on the history should be information regarding the regularity, flow, and any changes in the menstrual cycle; any pregnancies, miscarriages, or abortions; all birth-control methods used; the incidence of breast cancer in close female relatives; and whether the woman’s mother took the drug DES during her pregnancy with the patient—that is, whether the patient is a “DES daughter.” DES is a drug that was given in the 1940s and 1950s to women with a history of miscarriage. It is no longer used for miscarriages, because it has been found that vaginal cancer is more prevalent in DES daughters than in other women (Centers for Disease Control and Prevention, 2011a), and that women who took DES have breast cancer in greater numbers than non-DES women. If the patient’s mother did take DES, a periodic colposcopy, a check for changes in the vagina and cervix, should be conducted. The examiner uses an instrument called a colposcope to view the vagina for abnormal tissue growth. The examiner might also perform a biopsy.

colposcopy

An examination of the vagina and cervix using an instrument—a colposcope—to detect abnormal tissue growth.

FIGURE 4.13 Bimanual examination.

The most consistent research finding for DES sons is that they have an increased risk for noncancerous epididymal cysts, which are growths on the testicles (Centers for Disease Control and Prevention, 2011b).

Care from Organizations and Available Publications

For women, the ACS, the National Organization for Women, the March of Dimes, the National Women’s Health Network, women’s health centers and clinics, as well as local organizations of women who have had breasts removed due to cancer are but a few of the groups devoted to improving women’s reproductive health. These groups function in various ways: Some publish written material, others lobby for legislation and funds, and still others provide social support for women with reproductive health problems. In addition, clinics conduct medical examinations, test and care for STIs, and offer premarital blood tests and other services for women.

Exploring the Dimensions of Human Sexuality

Our feelings, attitudes, and beliefs regarding sexuality are influenced by our internal and external environments. Go to go.jblearning.com/dimensions5e to learn more about the biological, psychological, and sociological factors that affect your sexuality.

Case Study

The physiological development of a female starts when a sperm with an X chromosome fertilizes an egg. But socioeconomic status of the mother influences whether prenatal care is received, good nutrition will be available, and medical help will be sought. If the mother smokes, drinks, or abuses drugs during pregnancy, the fetus will be affected.

A woman’s physiology is further altered during puberty and menopause. The increased fat content at puberty negatively affects many women’s body image, which in turn negatively affects self-concept.

Unable to control the changes taking place within her body, the pubertal girl sometimes resorts to controlling the one thing she can control: food intake. Dieting is common, but excessive food control, or self-induced vomiting after meals, can result in a serious eating disorder.

Biological Factors

When a sperm with an X chromosome meets an egg (all of which have X chromosomes), a female will develop. Biological factors continue to influence development throughout life.

• • Genetic coding affects physical appearance, including height; coloration of skin, hair, and eyes; breast size; and many aspects of health.

• • Female physical appearance changes at puberty, when the lean-body-mass-to-fat ratio changes from about 5:1 to about 3:1, signaling the body to commence menarche.

• • Hormonal changes affect mood.

• • At menopause, lower estrogen levels increase a female’s risk for heart attack.

Sociocultural Factors

Sociocultural factors interact with biological factors to influence health.

• • Socioeconomic status influences prenatal care and nutrition.

• • Ethnic heritage influences health. African American women tend to get a more virulent form of breast cancer, resulting in a higher death rate. Jewish women are genetically at risk for scoliosis (curvature of the spine).

• • Culture influences women’s health. Fear of Western medicine prevents some immigrants from seeking treatment at early stages of a problem.

• • Media and ads that present ultrathin women as ideals can influence the eating patterns and health of women.

Psychological Factors

Psychological factors interact with other factors and can influence health.

• • Women tend to have nearly twice the rate of depression of men.

• • Teen women with low self-concept have a higher probability of having an unwanted pregnancy and birth.

• • Expressiveness of emotions helps women stay mentally and physically healthy.

• • Learned attitudes and behaviors about gender roles can prevent a woman from fulfilling her potential.

• • Body-image problems in women can lead to long-term disorders, such as bulimia and anorexia nervosa.

Summary

• • The external female genitals (the vulva) consist of the mons pubis, labia majora, labia minora, clitoris, vestibule, and urethral opening.

• • The clitoris is protected by the clitoral hood and is very sensitive because it contains many nerve endings.

• • The internal female genitals consist of the vagina, uterus, fallopian tubes, and ovaries.

• • In the vagina, the outer one-third contains the most nerve endings. As a result, the length of the penis is generally irrelevant to sexual satisfaction. Furthermore, the vagina contracts around an object inserted in it, making the width of the penis also generally irrelevant to sexual satisfaction.

• • The uterus consists of three layers: the perimetrium, which is elastic, thereby enabling the uterus to stretch during pregnancy; the myometrium, which is made up of smooth muscle, thereby helping to push the baby through the cervix; and the endometrium, which is loaded with blood vessels, thereby providing the nourishment needed to sustain a developing fetus.

• • Hormones control menstruation. Follicle-stimulating hormone (FSH) stimulates the ovary to ripen an ovum, luteinizing hormone (LH) signals the Graafian follicle to release the ripened ovum, estrogens signal the pituitary gland to release LH, and progesterone released by the corpus luteum prepares the uterus for implantation of the fertilized ovum.

• • Menstrual problems include dysmenorrhea (painful menstruation), which can be either primary or secondary; amenorrhea (a lack of menstruation); and premenstrual syndrome (menstruation associated with bloating cramping, fatigue, depression, headache, and other symptoms).

• • The breast is the leading site of cancer in women, and breast cancer is the second leading cause of cancer deaths among women. Breast care consists of breast self-exams (although some groups recommend not doing breast self-exams), annual clinical breast exams, and mammograms as recommended. In addition, women should have annual gynecological exams and Pap smears as recommended.

Discussion Questions

1.

List and describe the parts of the female reproductive system, including external and internal genitalia.

2.

Compare the roles of breasts as child nurturer and sexual organ.

3.

Describe how hormones react to sexual stimuli and make a person aroused.

4.

Which physiological changes occur in a woman’s body during the menstrual cycle? What are the resulting psychological effects?

5.

For which diseases of the reproductive system is a woman at risk? How can she prevent these diseases?

6.

Describe the self-care and preventive medicine that a woman should practice to ensure her sexual health.

Application Questions

Reread the anecdote that opens the chapter and answer the following questions.

1.

How could you use your understanding of the parts of the human body to improve your sexuality? Is such knowledge as important as the ability to communicate or to understand the diverse needs of a partner? Put another way, would an expert on sexuality be a better lover?

2.

Describe how you feel when you look at anatomical drawings of genitalia. Do you feel sexually excited? Embarrassed? Bored? Explain why you feel that way.

Critical Thinking Questions

1.

Some women argue that only another woman can really understand the feelings and sensations that a woman feels, that male gynecologists are likely to discount some female concerns, and that it is easier to talk with another woman than a man about their sexual health. Others may argue that medical competency and compassion are not limited by gender. Should a gynecologist be a woman? Explain your answer.

2.

If you look at the women on TV, in movies, and in magazines, the pervasive image is clear: lean and busty. Yet the psychologist G. Terence Wilson, an eating disorder specialist, points out that a woman cannot be lean and have large breasts—it is not biologically possible. As a woman loses fat, her breasts reduce in size. Should a woman who finds herself lean and flat get breast implants or regain weight so her breasts will be larger? Explain your answer.

Critical Thinking Case

As discussed in the chapter, some researchers believe that onset of menarche occurs on the basis of body composition—namely, when a woman reaches a certain percentage of body fat. It also appears that amenorrhea (cessation of menstruation) occurs in women athletes with low body fat and in women with anorexia nervosa.

Consider the negative connotations associated with body fat in our society, especially as portrayed in the mass media. What reaction might prepubes-cent girls have to learning that they will gain body fat and then reach menarche? How could middle and high school students be taught in a positive manner about the body composition changes associated with the onset of menarche? Would such knowledge lead young girls to diet to prevent menarche?

One final question: A very athletic person in your dormitory tells you that she has heard about the relationship between body fat and amenorrhea. She tells you that she does strenuous aerobic exercise as a means of what she calls “natural birth control.” What would you tell her?

Exploring Personal Dimensions

For Women Only

Taking charge of self-care and prevention greatly increases your chance of achieving sexual health and wellness. If you are a female, for the following statements, circle YES or NO. Then fill in the dates to help you keep track of your self-care activities.

Suggested Readings

Alexander, L. L., LaRosa, J. H., Bader, H., & Garfield, S. New dimensions in women’s health. Sudbury, MA: Jones & Bartlett Learning, 2009.

Carlson, K. J., Eisenstat, S. A., & Ziporyn, T. D. The new Harvard guide to women’s health. Cambridge. MA: Harvard University Press, 2004.

Goldberg, N. Dr. Nieca Goldberg’s complete guide to women’s health. New York: Ballantine Books, 2009.

Heffner, L. J., & Schust, D. J. The reproductive system at a glance, 3rd ed. Hoboken, NJ: Wiley-Blackwell, 2010.

Morris, D. The naked woman: A study of the female body. New York: St. Martin’s Press, 2007.

Schuiling, K. D., & Likis, F. E. Women’s gynecologic health. Sudbury, MA: Jones & Bartlett Learning, 2011.

Staff of Boston Women’s Health Book Collective. Our bodies, ourselves: A new edition for a new era. New York: Simon & Schuster, 2005.

World Health Organization. Mental health aspects of women’s reproductive health: A global review of the literature. Geneva, Switzerland: World Health Organization, 2008.

Web Resources

For links to the websites below, visit go.jblearning.com/dimensions5e and click on Resource Links.

Inner Body: Your Guide to Human Anatomy Online: Female Reproductive System

www.innerbody.com/image/repfov.html

An overview of the female reproductive system with diagrams and detailed information about each structure, including the mammary glands, cervix, fallopian tubes, labia minor, ovary ligaments, ovaries, uterus, vagina, and vulva.

SexualHealth.com

www.sexualhealth.com/channel/view/women-sexual-health/

Presents information on women’s sexual health topics such as desire, pleasure, orgasm, medications and supplements, gynecological concerns, pain during intercourse, menopause, menstruation and breast health, infertility, pregnancy and childbirth, masturbation, body image, and contraception.

National Woman’s Health Network

http://nwhn.org/

The National Women’s Health Network seeks to improve the health of women by developing and promoting a critical analysis of health issues in order to affect policy and support consumer decision making. The Network aspires to a healthcare system that is guided by social justice and reflects the needs of diverse women. On the website, women’s health information and resources, as well as health alerts, are provided.

National Women’s Health Information Center

www.4women.gov

A website maintained by the U.S. government that provides resources and information about women’s health issues. Includes health topics, health organizations, statistics, publications, and other links.

Society for Women’s Health Research

www.womenshealthresearch.org

The Society for Women’s Health Research is a nonprofit organization whose mission is to improve the health of women through research, education, and advocacy. The society encourages the study of sex differences between women and men that affect the prevention, diagnosis, and treatment of disease. The information provided on this site is designed to support, not replace, the relationship that exists between a woman and her doctor.

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Centers for Disease Control and Prevention. About DES: Known health effects for DES sons, 2011b. Available: http://www.cdc.gov/DES/consumers/about/effects_sons.html.

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CHAPTER 5 Male Sexual Anatomy and Physiology

FEATURES

•  Global Dimensions Male Genital Mutilation and Circumcision Practices

•  Ethical Dimensions What Are a Dead Man’s Rights?

•  Ethical Dimensions Should Physicians Have to Provide Care Regardless of Their Personal Values or Moral Convictions?

•  Multicultural Dimensions PSA Cancer Screening

•  Gender Dimensions Testicular Self-Examination

CHAPTER OBJECTIVES

• 1 Name and describe the parts of the male reproductive system to include the external and internal genitalia, including the pathway of the sperm.

• 2 Discuss the role of hormones in males as they enter puberty.

• 3 Cite various diseases that can affect the male reproductive system and the self-care procedures, as well as medical treatments, associated with these diseases.

go.jblearning.com/dimensions5e

Global Dimensions: Male Genital Mutilation and Circumcision Practices

Prostate Cancer

Care from Organizations and Available Publications

INTRODUCTION

An economics professor recently told me that a father had come in to talk about his son’s mediocre academic performance. The father asked for a second chance for his son, explaining that “too often he thinks with his other head.” Of course, this is not the first time I had heard this suggestion that men “think with their penises.”

The notion goes back to the fifth century. In the Greek comedy Lysistrata, the women of the city decide to withhold sex from their men until all wars are ended. The men quickly put their civic pride aside in favor of their women—thinking with their “other heads,” no doubt!

However, today’s man may think more about his penis than with it. And the great obsession seems to be size. In the mid-1900s a national sex survey found that men thought the average length of a penis was 14 inches; women thought it was 12 inches. However, the average length is really about 6 inches!

Magazines like Penthouse Forum do not help, either. Chock-full of large appendages—10 inches here, 8 inches there, a “foot long” here, as “thick as his arm” there—the stories are meant to present fantasy, not reality.

The writer Susan Minot provides an interesting perspective in her short story “Lust.”

• Tim’s was shaped like a banana, with a graceful curve to it. They’re all different. Willie’s like a bunch of walnuts when nothing was happening, another’s as thin as a thin hot dog. But it’s like faces; you’re never really surprised.

As you will read in this chapter, for all the worry that men may feel, it is quite natural for men’s penises to vary considerably, just as their faces do.

 The Male Reproductive System

As females do, males have both external and internal genital organs. Figure 5.1 depicts a side view of the male external and internal genitalia, and Figure 5.2 shows a view from the rear. We begin our study of the male reproductive system with the external genitals.

The External Genitals

The male external genitals are the penis and the scrotum.

The Penis

The penis is a male sexual organ consisting of the root, the shaft, and the glans. As we have mentioned, penis size concerns many students, who often ask about the “average-size penis.” As a general guideline, the average penis is about 2–5 inches long when relaxed (flaccid) and about 4–7 inches long when erect. When sexually aroused, the penis becomes stiff and enlarged (erect) because its tissues fill with blood. The penis shaft is attached to the body by its root. The head of the penis is called the glans penis. The glans contains the urethral opening, or meatus, where both seminal fluid (which contains sperm) and urine are passed. Marking the end of the glans is a raised ridge called the coronal ridge, or corona. The coronal ridge helps to form a seal with the walls of the vagina during sexual intercourse. Below the corona the body, or shaft, of the penis begins. Although the entire penis is sensitive and sexually excitable, the glans and corona are particularly sensitive; in fact, they are the most sensitive parts of the male anatomy.

penis

Structure of the male external genitalia consisting of the root, shaft, and glans; also contains the urethra, through which urine is excreted.

glans penis

The head of the penis.

meatus

The opening of the urethra in the head of the penis, where both seminal fluid and urine are passed.

coronal ridge (corona)

The raised ridge where the glans penis ends and the penile shaft begins.

FIGURE 5.1 Side view of the male reproductive organs.

Historically penis size has been a matter of fascination. The Kamasutra, an ancient Indian book on erotica, classified men according to penis size in three categories: hare-men (erect penises of approximately 4.5 inches [11 centimeters]), bull-men (erect penises of approximately 6.75 inches [17 centimeters]), and horse-men (erect penises of approximately 9 inches [23-centimeters]). Other sources correlated penis size with personality traits or with the size of some other part of the body. Penises that are short when flaccid gain more size during erection than those that are longer when flaccid. Thus, although flaccid penises may differ significantly in length, erect penises are of similar lengths (Delvin & Webber, 2008). One way this has been described is that some men are “showers” and others are “growers” (Haffner & Schwartz, 1998).

Kamasutra

Ancient sex manual from India.

flaccid

The relaxed, unerect state of the penis.

erection

The extension of the penis and its engorgement with blood when the male is sexually stimulated.

FIGURE 5.2 Posterior view of the male reproductive organs.

Two contradictory views regarding penile size flourish in our time: “The larger the penis, the more satisfied the sexual partner” and “Sexual partners don’t care about the size of a man’s penis.” It is not clear which is nearer the truth. Because the vagina adapts to the penis regardless of its size, some people have argued that size is unrelated to the sexual satisfaction of the female. However, part of our response to another’s body is visual, and it seems reasonable to assume that if people have preferences for breasts of certain sizes and shapes, so might they react differently to penises of different shapes and sizes. None of these preferences has anything to do with function unless it causes anxiety. The vagina contracts around the penis, regardless of its width or circumference. Furthermore, the inner two-thirds of the vagina has very little sensitivity. Both of these facts lead most authorities to conclude that penile width or length is unrelated to sexual satisfaction. Some people do, however, report preference for penises of a certain width or length. Whether these preferences are physiological or psychological is unknown at this time.

Just as women can strengthen the pelvic musculature with Kegel exercises, so can men strengthen the muscles surrounding the penis. Because these muscles are usually contracted only during ejaculation, they tend to be weak. By strengthening the muscles surrounding the penis, men may experience more satisfying orgasms and maintain better control of ejaculation. To do male Kegel exercises (National Kidney and Urologic Diseases Information Clearinghouse, 2007):

Many variations exist in the size and shape of the male genitals.

• 1. Identify the right muscles by imagining that you are trying to stop yourself from passing gas or urinating. Squeeze the muscles you would use. If you sense a “pulling” feeling, those are the right muscles for pelvic exercises.

• 2. Do not squeeze other muscles at the same time or hold your breath. Also, be careful not to tighten your stomach, leg, or buttock muscles. Squeezing the wrong muscles can put pressure on your bladder control muscles. Squeeze just the pelvic muscles.

• 3. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Repeat, but do not overdo it. Work up to 3 sets of 10 repeats.

• 4. Start doing your pelvic muscle exercises lying down. This position is the easiest for doing Kegel exercises because the muscles then do not need to work against gravity. When your muscles get stronger, do the exercises sitting or standing. Working against gravity is like adding more weight.

• 5. Be patient. Do not give up. It takes just 5 minutes, 3 times a day. Your ejaculatory control may not improve immediately, but most people notice an improvement in approximately 1 month.

Circumcision

The glans penis is covered by a foreskin (sometimes called the prepuce). For hygienic, cultural, or religious reasons, the foreskin is sometimes surgically removed. Removal of the foreskin—called circumcision—is more usual in the United States than in European countries. Circumcision takes place in the hospital approximately 2 days after birth or, if performed according to Jewish custom, 8 days after birth. In addition to Judaism, the Muslim faith requires circumcision. Figure 5.3 shows how circumcision is performed.

foreskin (prepuce)

The covering of the glans penis, which is removed during circumcision.

circumcision

The surgical removal of the foreskin covering the glans penis.

Hygiene also provides a rationale for circumcision. Several preputial glands—glands that secrete hormones only after puberty—are located in the foreskin and under the corona (Tyson’s glands). These glands secrete an oily substance that, if not removed from under the foreskin, can combine with dead skin cells to form a cheesy substance called smegma. If this smegma is not regularly removed from under the foreskin, it becomes granular and irritates the glans penis, causing discomfort and possibly infection. Removing the smegma requires washing the glans penis. This becomes more difficult if the foreskin is not removed, because it has to be retracted manually to expose the glans.

smegma

A cheeselike substance secreted by the glans penis that must be removed from below the foreskin of uncircumcised males to prevent irritation and/or infection.

Since 1971, the American Academy of Pediatrics (AAP) has released several statements noting that there is no medical reason for circumcision. As a result, circumcision rates in the United States dropped from a high of 95% of newborn males in the mid-1960s to an estimated 58% in 1987 (Rovner, 1990). However, in 1990, the Academy (Brower, 1989) reversed its position, citing advantages based on the work of Dr. Thomas Wiswell and colleagues (1985). Wiswell found that uncircumcised infants were 10 times more likely to have urinary tract infections than circumcised babies. Wiswell also reported that of 50,000 cases of cancer of the penis over a 50-year period, only 10 occurred in circumcised men.

FIGURE 5.3 Methods of performing circumcision. (a) In this method, a piece of plastic is placed over the glans, and the foreskin is stretched over the plastic and trimmed off. (b) In this method, the foreskin is carefully cut “freehand” and then stitched.

However, not everyone agrees with the AAP’s 1990 position. For example, Smith and colleagues (1987) found no difference in rates of urinary infections, and other researchers have reached similar conclusions over the years (Samuels & Samuels, 1983; Wallerstein, 1980). More recently, however, AAP has advised that the benefits of circumcision are not significant enough to recommend it as a routine procedure (American Academy of Pediatrics, 1999). This policy was reaffirmed by the AAP in 2005 and is the current policy of the AAP (American Academy of Pediatrics, 2011).

But another argument attempts to justify circumcision: The foreskin interferes with sexual stimulation because it serves as a barrier to the glans penis. There are no data to support this argument and, in fact, logic would indicate otherwise. The foreskin retracts when the penis becomes erect, and the glans penis is, therefore, able to be stimulated just as it is for the circumcised male. Furthermore, some people have argued the opposite: That is, if the glans is not usually protected by a foreskin, it may become insensitive because of its repeated contact with clothing. Therefore, the circumcised penis may, in fact, be less sensitive than the uncircumcised penis. Neither viewpoint is conclusive.

Still other reasons have been offered to justify circumcision. For example, uncircumcised males may be at greater risk of penile cancer, and their female sexual partners may be at greater risk of vaginal infections, cervical cancer, genital warts, and other sexually transmitted infections. However, for every study that supports these concerns, there appear to be studies that refute them.

There are more reasons for not being circumcised. First is concern about the trauma the infant experiences. Because infants cannot be administered general anesthesia or pain-relieving narcotic agents, circumcision is often performed without the benefit of anesthesia. To respond to this concern, some physicians inject a local anesthetic directly into the penis in an attempt to diminish or eliminate the pain associated with circumcision. Another issue is the risk of infection, hemorrhage, emotional trauma, and other effects associated with any surgical procedure.

Yet, there is agreement among medical experts that when the foreskin is so tight that an erection hurts or pain is experienced during sexual intercourse, removal of the foreskin is recommended. This condition is known as phimosis.

phimosis

Condition resulting when penile erection causes pain because the foreskin is too tight.

To summarize, here are reasons parents might consider circumcising their son:

• • They are Jewish or Muslim. Infant circumcision is part of these religious traditions.

• • If the father is circumcised, parents might want their son’s penis to be like his father’s penis.

• • Parents do not want to have to teach their sons to clean their foreskins.

• • Circumcised men have a lower incidence of urinary tract infections.

• • Some uncircumcised men have problems as they grow up, for example, pain during intercourse, requiring circumcision during adulthood. This is much more painful and dangerous than newborn circumcision.

• • The rate of cancer of the penis, though extremely rare, is higher in uncircumcised men.

• • Uncircumcised men may be more susceptible to sexually transmitted infections.

Here are reasons parents might not want to circumcise their son:

• • Circumcision is not part of their cultural tradition.

• • Circumcision is painful for infants.

• • If the father is not circumcised, parents might want their son’s penis to be like his father’s penis.

• • As with any surgery, circumcision poses some risks. In rare cases (less than two times in 1,000) infection or even damage to the penis occurs.

• • They think circumcision is not natural. Boys are born with penises with foreskins; their intact penises should be left alone.

• • Circumcision is done without the infant’s permission. This should be an adult choice.

• • The child is ill at birth. Circumcision should never be done on a sick or medically unstable infant.

 Global DIMENSIONS: Male Genital Mutilation and Circumcision Practices

Around the world and throughout history there have been many societies that have practiced male genital mutilation. For example, castration, the removal of the testes, was common in ancient Rome; eunuchs, castrated men, dressed as women and became priests. Islamic societies are forbidden by the Koran to castrate men. Yet they used men castrated by the Christians as keepers of the harem, because they posed no threat of engaging in sexual activities. In addition, boys were castrated in the Middle Ages in Europe to maintain their soprano singing voices after puberty.

In some societies in the Pacific, men are circumcised, but the foreskin is not totally removed; instead, it is slit lengthwise and folded back. This is called supercision. Sometimes the foreskin is stretched tightly over a piece of bamboo, and then the incision is made. Circumcision is often associated with entry into manhood in these cultures and is usually celebrated with a ceremony of some sort.

The Scrotum

The other external structure of the male reproductive system is the scrotum, which is located below the penis. The scrotum is a sac of skin containing the testes and the spermatic cords. It comprises two layers: the outer layer, which is covered with hair and sweat glands, and the inner layer (called the tunica dartos), which contains muscle and connective tissue. This organ regulates the temperature in the testes by drawing them up toward the body when the body is cold and letting them hang lower, away from the body, when it is hot. As a consequence the temperature of the testes is always approximately 5.6°F (3.1°C) cooler than the internal body temperature. This temperature-control function is necessary for the production of viable sperm. The scrotum also contracts when the inner thigh is stimulated or when it is chilled. This effect, is due to the contraction of the cremasteric muscles located in the spermatic cord, which is known as the cremasteric reflex.

scrotum (scrotal sac)

A sac of skin that contains the testes and spermatic cords.

testes

Male gonads contained within the scrotal sacs that produce sperm cells and the male sex hormone testosterone. Singular form: testicle.

spermatic cord

The cord from which the testicle is suspended that contains the vas deferens (defined later), blood vessels, nerves, and muscle fibers.

The Internal Genitals

The male internal genitals contain numerous organs housed within the penis, the scrotum, and the pelvis (refer again to Figure 5.1).

The Urethra

The urethra is a tube through the penis that begins at the bladder and ends at the meatus. Its function is to provide a route for both semen and urine to exit the body. Urine is a waste product of the body that is stored in the bladder until it is expelled through the urethra. Semen, which is discussed later in this section, contains spermatozoa, or sperm, as well as other substances.

urethra

The tube through which the bladder empties urine outside the body and through which the male ejaculate exits.

urine

The body-waste product stored in the bladder and eliminated through the urethra.

semen

The male ejaculate, which contains sperm and other secretions.

spermatozoa (sperm)

The mature male sperm cell.

The Corpora Cavernosa and the Corpus Spongiosum

In addition to the urethra, the penis contains three spongy bodies: two corpora cavernosa and the corpus spongiosum, which are structures filled with networks of blood vessels and nerves. It is these columns of tissue, which fill with blood during sexual arousal, that make the penis grow hard and erect. During ejaculation the muscle surrounding the corpus spongiosum (the bulbocavernosus muscle) contracts and forces semen outward through the urethra.

corpora cavernosa

A spongy body in the penis that contains a network of blood vessels and nerves.

corpus spongiosum

A spongy body in the penis that contains a network of blood vessels and nerves.

Myth vs Fact

Myth: Whereas females can strengthen their pelvic muscles, thereby exercising better control of their sexual response, there is not much males can do.

Fact: Males can strengthen their pelvic muscles also. They can perform Kegel exercises to strengthen the muscles surrounding the penis, thereby achieving more satisfying orgasms and maintaining better control of ejaculation.

Myth: There is no medical reason for males to be circumcised.

Fact: Recommendations regarding circumcision have changed over the years. More recently, it has been suggested that uncircumcised males may be at greater risk of penile cancer and that their female partners may be at greater risk of reproductive health problems. However, circumcision poses the risk of infection, hemorrhage, emotional trauma, and other conditions. Whether to be circumcised is a decision that needs a great deal of consideration.

Myth: Breast cancer affects women; men do not have to worry about contracting it.

Fact: Men can also contract breast cancer. In 2010 approximately 1,970 new cases of breast cancer were diagnosed, and 390 men died of it.

Myth: The ejaculate is made up predominantly of sperm.

Fact: The ejaculate, semen, consists mostly of seminal vesicle and prostate gland secretions. The volume of sperm is approximately the size of a pinhead.

Myth: A male with a small flaccid penis has much to worry about.

Fact: First, small flaccid penises tend to expand more during erection than do large flaccid penises. Second, the nerve endings in the vagina are in the outer third, making the length of the penis somewhat superfluous, at least as far as sexual satisfaction is concerned.

The Testes

As mentioned, the testes (Figure 5.4) are suspended in the scrotal sac by spermatic cords, the vas deferens (through which sperm leave the testes), blood vessels, nerves, and muscle fibers. The testes produce sperm (about 50,000 every minute) and testosterone, a male sex hormone generally responsible for male secondary sexual characteristics (for example, deep voice, facial hair, and body hair). Within each testicle are approximately 1,000 seminiferous tubules, which are responsible for producing sperm, in a process called spermatogenesis. The cells between the seminiferous tubules, called interstitial cells, produce testosterone.

vas deferens

The duct, through which sperm stored in the epididymis (discussed later) is passed, that is cut or blocked during vasectomy.

testosterone

The male sex hormone produced in the testes that is responsible for the development of male secondary sex characteristics.

seminiferous tubules

The structures located within the testes that actually produce the sperm.

spermatogenesis

The manufacturing of sperm in the seminiferous tubules.

interstitial cells

The cells (sometimes called Leydig’s cells) between the seminiferous tubules, where testosterone is produced.

FIGURE 5.4 Testicle cross section.

Once sperm are produced in the seminiferous tubules, they travel through the vasa efferentia to the epididymis, where they are stored and nourished for up to 6 weeks.

vasa efferentia

The duct through which sperm produced in the seminiferous tubules travel to the epididymis.

epididymi

The location where sperm are stored in the testes and where nutrients are provided to help the sperm develop.

The Pathway of the Sperm

A mature sperm is about 0.0024 inch (0.0060 centimeter) long, with a head, neck, midpiece, and tail. The normal sperm contains 23 chromosomes. Each sperm contains a sex chromosome that determines the sex of the offspring. Sperm can be stored for up to 6 weeks in the epididymis before proceeding up the vas deferens to the ampulla (an enlarged portion of the vas deferens). Here in the ampulla the sperm receive more nutrients from the seminal vesicles, two sacs, each about 2 inches (5 centimeters) long, that secrete a substance believed to activate the sperm’s motility (ability to move spontaneously).

ampulla

The enlarged portion of the vas deferens where sperm are provided nutrients from the seminal vesicles; also, the part of the fallopian tube of women containing the cilia.

seminal vesicles

Two sacs of the male internal genitalia that secrete nutrients to nourish sperm.

motility

The ability to move spontaneously, which is required for fertilization.

 Did You Know . . .

• 1. Testosterone causes bones to thicken and for this reason is sometimes administered to elderly people who have osteoporosis.

• 2. Excessive concentrations of sex hormones are metabolized primarily in the liver, with the products excreted in the bile and urine. Consequently, people with liver disorders experience the effects of excessive sex hormones (for example, the development of excessive body hair, development of breasts, or aggressiveness).

• 3. Sex hormones stimulate growth, thereby explaining the rapid growth that occurs during puberty. However, they also stimulate ossification (hardening) of the epiphyseal disks (a band of cartilage at the end of the bone), which causes bones to stop growing. Because estrogens produce greater effects on the disks than androgens, females stop growing earlier than males.

With sufficient sexual stimulation, the ejaculatory process begins. Fluid from the prostate gland mixes with the sperm and with the secretions of the seminal vesicles, further aiding sperm motility and prolonging sperm life. The prostate fluid is an alkaline medium that offsets the acidity in the vagina that would otherwise kill the sperm. The Cowper’s glands, two pea-sized glands adjacent to the urethra, empty into the urethra another alkaline fluid, which serves to neutralize the acidity caused by the urethra’s transport of urine. The Cowper’s glands secretions are the tiny droplets that sometimes appear on the tip of the penis before ejaculation. This secretion may contain some sperm left over from a previous ejaculation; therefore, it can cause pregnancy to occur even if the penis is withdrawn before ejaculation.

prostate gland

A structure of the male internal genitalia that secretes a fluid into the semen before ejaculation to aid sperm motility and prolong sperm life.

Cowper’s glands

Two pea-sized glands adjacent to the urethra that secrete a lubricating fluid before ejaculation.

Ejaculation itself is the expulsion through the penis of semen, the mixture in which the sperm are carried. Ejaculation results from muscular contractions of the glands and ducts of the reproductive system. The expelling of semen is usually accompanied by orgasm, the climax of a growing complex of pleasurable sensations. Both the ampulla and seminal vesicles contract, as does the bulbocavernosus muscle surrounding the corpus spongiosum in the penis. The ejaculated semen contains sperm (the volume is about the size of a pinhead) and about a teaspoonful of secretions from the seminal vesicles, the prostate gland, and the Cowper’s glands. Approximately 300 million sperm are expelled in a single ejaculation. According to some authorities, semen contain at least 20 to 35 million sperm per cubic centimeter in a male who is fertile—that is, able to fertilize an ovum.

ejaculation

The ejection of semen from the penis during orgasm.

orgasm

The peak release of sexual tension, accompanied by sensory pleasure and involuntary rhythmic muscular contractions; ejaculation in the male.

During ejaculation a valve at the bladder’s entrance closes to prevent urine from entering the urethra.

Table 5.1 reviews the functions of the male reproductive system.

TABLE 5.1 Functions of the Organs of the Male Reproductive System

 Hormones

At some time during puberty, boys become capable of reproduction. This capability is accompanied by the ability to ejaculate, although initially the male’s ejaculate does not contain mature sperm. The cause of male reproductive capacity is the increased secretion of androgens, followed by the development of secondary sex characteristics. Accompanying male reproductive capacity, and also a result of increased androgen production, is a heightened interest in sex. This can be considered double jeopardy, because an increase in sexual appetite in a person newly capable of fertilizing an ovum can create problems—such as unplanned pregnancy or frustrated libido. The majority of both males and females seem to adjust to this new condition and pass through this phase of life unscarred. Unfortunately some do not, as evidenced by the high rate of pregnancy in unmarried teenage girls.

libido

Sexual desire, or drive.

 Ethical DIMENSIONS: What Are a Dead Man’s Rights?

The Center for Bioethics at the University of Pennsylvania documented 25 cases in which sperm were taken from dead men and preserved by deepfreezing. Furthermore, a survey of 273 fertility centers in the United States identified 82 requests for taking sperm from dead men, of which 25 had been honored. It is possible to remove sperm up to 24 hours after death, and the person most often making the request is the widow. However, there also are records of social workers and even an intensive care nurse who made such a request.

Who has a right, if anyone at all does, to have such a request honored? Only the spouse, or a parent as well?

Should men have the right to decide whether they will have children and with whom, even after they are dead?

Should sperm taken from dead men be used by women unrelated to them, whose husbands do not produce viable sperm? Who else should have access to this sperm?

Should the sperm be sold and the proceeds go to the man’s family? What should be done with the frozen sperm if the dead man’s family decides not to use them?

These are tough decisions that should be guided by ethical principles.

During puberty, increased testosterone level leads to growth of the penis, prostate, seminal vesicles, and epididymis. The reason males cannot ejaculate before puberty is that the prostate and seminal vesicles are not functional until they are “turned on” by the increased level of testosterone. Late-developing boys (15 to 16 years old) have been found to experience less sexual activity during adolescence than do early developers (Kinsey, Pomeroy, & Martin, 1948; Masters, Johnson, & Kolodny, 1982, 169). This difference has been attributed to the effect of testosterone on increasing the sexual appetite in males. No long-lasting effect on sexual behavior has been reported, however.

Hormone Therapy

Hormone therapy is sometimes administered to men. For instance, testosterone supplements are sometimes administered to treat erectile dysfunction in older men (although testosterone levels are not low in all men who have trouble maintaining erection). Sometimes this treatment for erectile dysfunction is effective; other times it is not. The reason for this inconsistency is unclear; however, it is safe to say that the complex nature of sexuality makes it only partially responsive to hormone treatment. Testosterone supplements may not have much effect when personality, past experiences, the sexual partner, effectiveness in communication, setting, and so on, continue to have negative effects.

 Self-Care and Prevention

Male reproductive care is as specialized as female reproductive care. Men should learn proper hygiene and methods of monitoring their reproductive health. When problems arise, males should consult their own medical specialists (internists or urologists). As with females, there are many organizations and publications that focus exclusively on issues of male reproductive health.

 Did You Know . . .

Androstenedione is the supplement that Mark McGwire made famous during his 70-home-run season. Touted as an artificial steroid, it was said to raise testosterone levels. But researchers at the University of Iowa found that it did not raise testosterone levels or increase strength. A side effect was lower levels of “good” cholesterol (high-density lipoproteins), raising the risk of heart disease. Preliminary results of a further study by the Harvard researcher Hoel Finkelstein for Major League Baseball showed that androstenedione raised estrogen levels in men—and could result in breast enlargement!

Source: Data from Body-building aid questioned, CBSNews (June 3, 1999). Available: www.cbsnews.com/2100-204_162-493000.html.

 Ethical DIMENSIONS: Should Physicians Have to Provide Care Regardless of Their Personal Values or Moral Convictions?

One month before George W. Bush’s presidency was to end, he finalized a regulation allowing health professionals to refuse to provide any medical service they objected to on moral grounds (Meckler, 2008). This “right of conscience” regulation was interpreted to mean that abortion, family planning, providing prescriptions for emergency contraception (the “morning after pill”), giving certain information or advice, or any other service the medical provider deemed immoral—even referrals for such services—could be withheld from the patient.

Those favoring such a regulation argue that no one—not even a health professional—should be required to behave in a manner that the person considers immoral. Furthermore, if the patient is denied a medical service, there will always be other medical staff willing to provide the desired service. Lastly, medical providers should not face the threat of being fired or losing a promotion because they refuse to do something they believe to be against their religious or moral beliefs.

Those opposed to the “right of conscience” regulation believe that because medical providers are licensed by the state, they are obligated to serve the medical needs of all citizens of that state. They also argue that the rule sacrifices the patient’s health to the religious belief of the providers (Savage, 2008). Furthermore, not providing a medical service requested by a patient, and not referring the patient to another healthcare provider from whom those services could be obtained, is doing harm to the patient and, therefore, is itself immoral and unethical.

Would you support a “right of conscience” regulation or do you agree with President Obama who rescinded it? What reasoning would you use when making this decision?

Breast Cancer in Men

Cancer of the breast occurs in men as well as women, although it is considered rare. An estimated 1,970 new cases of male breast cancer were diagnosed in 2010, and 390 men died of it that same year (American Cancer Society, 2010). Breast cancer is seen in men as early as their 30s. Although this cancer is rare, men are wise to examine their breasts for lumps. The procedure is the same for men and women.

It appears that several factors are related to the development of breast cancer in men. Among these are obesity, a lack of regular physical activity, and tobacco use (Brinton et al., 2008). Also, African American males have a higher incidence of breast cancer than do white males (Nahleh et al., 2007). In addition, as with women, breast cancer is more prevalent in men who carry the BRCA1 and BRCA2 genetic mutations (Tai et al., 2007). Another cause of concern is that male breast cancer is associated with a higher incidence of prostate cancer, suggesting careful screening for prostate cancer should be performed in men with breast cancer (Lee & Jones, 2008). In one large-scale study (Nahleh et al., 2007), male breast cancer patients survived an average of 7 years as compared to 9.8 years for female breast cancer patients. However, males in this study were diagnosed with breast cancer at a more advanced stage and with more lymph node involvement compared to the female patients. Furthermore, the male patients were diagnosed at a mean age of 67 years, whereas the female patients were diagnosed at a mean age of 57 years.

Treatment for male breast cancer is similar to that of female breast cancer with one major difference: The psychological and emotional consequences of breast removal are not as significant for males as for females. Consequently, men seldom need counseling or a cosmetic means of disguising breast-tissue removal.

The Prostate

An important self-care procedure involves the prostate gland. The symptoms of prostatitis (inflammation of the prostate) are pain in the lower back, pain in defecation, pain during a rectal exam, and pus in the urine. Prostatitis usually affects younger men and can be cured with antibiotic drugs. If you experience these symptoms, consult a physician.

prostatitis

Infection of the prostate gland.

An estimated 217,730 new cases of prostate cancer were diagnosed in the United States in 2010, and an estimated 32,050 men died of it that same year. Prostate cancer is the second leading cause of cancer deaths in men in the United States (lung cancer is the first). Between 1989 and 1992, prostate cancer rates increased dramatically, probably because of the use of a blood test developed to identify an antigen produced when prostate cancer is present. The blood test measures the presence of prostate-specific antigen (PSA). Since 1993, prostate cancer incidence rates have declined. It should be pointed out that prostate cancer incidence rates are one and one half times as high for African American men as they are for white men. The reason for this difference is not known, but some experts have conjectured that diets high in fat and/or the presence of a gene that may make the prostate more susceptible to the effects of testosterone may be the cause.

During a rectal digital exam, the physician feels for the size and texture of the prostate gland in an attempt to discover any abnormalities that need follow-up evaluation.

There are several factors that place a man at risk of development of prostate cancer. One of these is age. As a man gets older he becomes more susceptible to prostate cancer, although the cancer may have been present at a younger age but not fully developed. More than 70% of prostate cancers are diagnosed in men who are older than 65 years of age. Heredity is suspected of playing a role in perhaps 5% to 10% of cases.

Signs and symptoms include weak or interrupted urine flow; the need to urinate frequently, especially at night; blood in the urine; pain or burning when urinating; and persistent pain in the lower back, pelvis, or upper thighs. However, some of these symptoms may be caused by an enlargement of the prostate, which is common as men age, without the presence of a tumor. This condition is called benign prostatic hyperplasia (BPH) and can be treated with medications. The only way to distinguish BPH from prostate cancer is by a medical examination that includes a digital rectal examination (DRE), PSA blood test, and biopsy of the prostate. On June 12, 1997, the American Cancer Society published updated guidelines for prostate cancer screening (American Cancer Society, 1997). The guidelines state, “Both prostate specific antigen (PSA) and digital rectal examination (DRE) should be offered annually, beginning at age 50 years, to men who have a life expectancy of at least 10 years. Men at high risk (African American men and men with a family history of one or more first-degree relatives diagnosed with prostate cancer at an early age) should begin treatment at age 45.” The reason a 10-year life expectancy is cited is that prostate cancer is usually a slow-growing cancer; thus it is thought prudent for men to refrain from having treatment if they are not expected to live long enough to benefit from that treatment. These men would likely die of some other condition before the prostate cancer killed them. An abnormal PSA test result is one with a value above 4 ng/mL (some suggest above 2 ng/mL), which would then lead to follow-up evaluation and subsequent procedures. These may include a biopsy of tissue extracted from the prostate gland.

digital rectal examination (DRE)

A rectal examination whereby a physician inserts a finger into the rectum of a male patient to check for any abnormalities of the prostate.

 Multicultural DIMENSIONS: PSA Cancer Screening

There is disagreement among healthcare specialists about the advisability of men obtaining PSA screening for prostate cancer. The U.S. Preventive Services Task Force does not recommend PSA screening for men. By comparison, the American Cancer Society recommends annual screening for men 50 years of age and older. To further complicate matters, the American Medical Association and several other respected medical organizations suggest that clinicians discuss the potential benefits and known harms of PSA screening with their patients, and consider their patients’ preferences rather than routinely ordering PSA screenings.

One ethical principle guiding this kind of decision making is paternalism. Medical care providers who are advocates of paternalism argue that they are experts in health and, therefore, know more than their patients. It follows, then, that they can make a more informed and appropriate medical decision than can their patients. As a result, they are reluctant to discuss the pros and cons of screening with their patients and more comfortable making these decisions for their patients. This feeling of paternalism becomes even more pronounced when patients are minorities, or poorly educated. Given that some studies have found African American males are less knowledgeable about prostate cancer screening than white males (Chan et al., 2003; Barber et al., 1998), in spite of their higher incidence and mortality rates, the paternalism argument takes on added validity for some healthcare providers.

It seems to your authors that all men deserve to be informed about medical procedures available to them. After all, it is the patient—not the healthcare provider—who has to live with the outcomes of these procedures. If there is potential harm associated with PSA screening, we believe the patient should know that before consenting to the procedure.

In 2008, the U.S. Preventive Services Task Force, which evaluates medical screenings and makes recommendations regarding those screenings, published new guidelines for the use of the PSA test. It stated that men age 75 years of age and older should not be screened for PSA because the length of time one would die of prostate cancer is greater than 10 years, and a 75-year-old man’s average life expectancy is only 10 years. Therefore, older men should not be subjected to the test, as it could lead to other medical procedures. For men younger than 75 years, the Task Force stated, “Current evidence is insufficient to assess the balance of benefits and harms of screening.” In 2011, the Task Force went further and stated that all men, regardless of age, should not be routinely tested for PSA because the exam does not save lives and subjects men to unnecessary harm. The harms referred to relate to unnecessary medical procedures, such as biopsies and surgery; anxiety; and medical complications. The reasoning behind these recommendations pertains to the lack of evidence of the validity of PSA screening when a cutoff score of 4.0 ng/mL is used, as was standard practice. To respond to the lack of sensitivity of the screening at a score of 4.0 ng/mL, lowering the score to 2.5 ng/mL has been increasingly used. However, lowering the score leads to more false positives and, therefore, subjects men to more unnecessary biopsies and other medical procedures. Furthermore, two recent large-scale, long-term studies have concluded that PSA screening does not affect the prostate cancer death rate (Andriole et al., 2009; Schroder et al., 2009). The researchers found that the rate of death from prostate cancer was very low and did not differ significantly between the group of men who were screened and the group of men who were not.

Recognizing the controversy and lack of clear guidance, most major medical organizations recommend that clinicians discuss the potential benefits and known harms of PSA screening with their patients, and consider their patients’ preferences rather than routinely ordering PSA screening. Among these organizations are the American Academy of Family Physicians, American College of Physicians, American College of Preventive Medicine, and American Medical Association. In contrast, the American Urological Association recommends digital rectal examinations and PSA screening to men annually beginning at age 50 years.

If cancer is suspected, treatment consists of surgery, radiation, and/or hormonal therapy and chemotherapy if the cancer is in a late stage. However, because there is significant potential for serious side effects of these treatments (such as erectile dysfunction and/or incontinence), if the cancer is classified as low-grade and/or at an early stage, careful observation over a period without immediate treatment (called “watchful waiting”) may be advised.

Eighty-five percent of all prostate cancers are diagnosed while still localized, and these patients have a 100% 5-year survival rate. During the past 20 years, the 5-year survival rate for all prostate cancers increased from 67% to 97%. Seventy-nine percent of men with prostate cancer survive 10 years, and 57% survive 15 years.

The Testes

Testicular cancer is the most common form of cancer in men during late adolescence and early adulthood. Most cases occur in men aged 15 to 40 years. It is estimated that about 8,480 new cases of testicular cancer were diagnosed in 2010 and that 350 men died of testicular cancer that year (American Cancer Society, 2010). The testicular cancer risk is four times greater for white men than it is for African American men. The rate has doubled among white Americans in the past 40 years and has remained the same for African Americans.

testicular cancer

Cancer of the testicles; the most common form of cancer in men aged 29 to 35 years.

Among the risk factors for testicular cancer are undescended testes (cryptorchidism). Approximately 14% of cases of testicular cancer occur in men with a history of cryptorchidism. Other risk factors include a family history of testicular cancer, certain occupations (miners, oil and gas workers, leather workers, food and beverage processing workers, janitors, and utility workers), cancer of the other testicle, and infection with HIV. Testicular cancer is not related to injury or to vasectomy.

Treatment consists of surgery, radiation therapy, and/or chemotherapy. Surgery involves removal of the testicle. A cut is made in the groin, and the spermatic cord and the testicle are withdrawn from the scrotum through the opening. This procedure is called a radical inguinal orchiectomy. Depending on the stage of the cancer, some lymph nodes may also be removed. With only one testicle removed, the patient remains fertile. However, if two testicles need to be removed, the patient will no longer be able to produce sperm. Another side effect of the surgery is the possibility of damage to the nerves that control ejaculation. Damage to these nerves may also cause infertility. Men who still wish to have biological children can store sperm in a sperm bank for use after the surgery.

Treatment is highly effective if the cancer is diagnosed early. Ninety-five percent of stage 1 cancers can be cured, 90% to 95% of stage 2 cancers can be cured, and approximately 70% of stage 3 cancers can be cured. The lower the stage number, the earlier the cancer was diagnosed.

 Gender DIMENSIONS: Testicular Self-Examination

In the recent past, males were advised to perform testicular self-examinations in the hope of identifying testicular cancer at its earliest stage. However, after examining the pros and cons of such self-exams, the United States Preventive Services Task Force (2010) recommended that such tests not be performed. As with breast self-exams, the Task Force concluded that the potential harms outweighed the potential benefits of testicular self-exams. Still, any abnormalities found in the testicles should be immediately reported to a physician.

Any lumps, masses, or thickened areas may be symptoms of abnormality, not always cancerous; however, medical diagnosis and consultation are imperative. As with other forms of cancer, early diagnosis increases your chance of survival.

The Penis

Penile discharges of pus, painful urination, itching, or sores or warts on the genitals may indicate the presence of a sexually transmitted infection. Also, as suggested earlier in this chapter, men should make sure that smegma is washed away daily to prevent irritation or infection in themselves and their partners. For circumcised males, keeping the penis smegma-free is easy, involving rolling only a little of the remaining foreskin out of the way during normal showering. Uncircumcised men have to be more careful, pulling back the foreskin and washing the glans and the inside of the foreskin.

Bicycle Riding and Sexual Health

The area between the penis and the anus is called the perineum; it is where the perineal nerve is located. Researchers have found that the perineal nerve is compressed during bicycle riding of three hours per week or longer and that blood flow to the area can be impaired as a result (Huang, Munarriz, & Goldstein, 2005). That can lead to numbness in the penis and perineum and is associated with the onset of erectile dysfunction (Marceau et al., 2001). Erectile dysfunction is the inability to achieve penile erection.

The possibility that this problem might occur does not mean, however, that men should not ride bicycles for protracted periods of time. A minor adjustment in the bicycle saddle can prevent this condition. The bicycle saddle should be changed from the traditional one with a protruding nose to no-nose saddle (Lowe, Schrader, & Breitenstein, 2004). In a study of bicycle police officers, who spend a considerable amount of time riding their bicycles, a no-nose saddle was found to reduce perineum pressure and decrease symptoms (Schrader, Breitenstein, & Lowe, 2008).

Care from Organizations and Available Publications

Several organizations aid men in caring for their reproductive health: The American Cancer Society publishes brochures and pamphlets; local health departments operate clinics providing medical examinations, testing, and care for STIs, premarital blood tests, and counseling about birth control and sexual problems. Other organizations, such as the National Cancer Institute, keep track of the incidence and frequency of diseases related to reproductive health. And still other organizations, such as the Health Research Group, a nonprofit group devoted to studies to improve health care, conduct research to prevent and treat various conditions affecting the male reproductive system.

Exploring the Dimensions of Human Sexuality

Our feelings, attitudes, and beliefs regarding sexuality are influenced by our internal and external environments. Go to go.jblearning.com/dimensions5e to learn more about the biological, psychological, and sociological factors that affect your sexuality.

Biological Factors

When a sperm with a Y chromosome meets an egg, a male offspring will develop. Biological factors continue to influence development throughout life.

• • Genetic coding affects physical appearance, including height; coloration of skin, hair, and eyes; muscularity; and many aspects of health.

• • Physiological changes result at puberty from the hormone testosterone, which in turn affects muscle development and body size. Testosterone also increases aggression and leads to increased rates of heart attacks.

• • Toward middle age, testosterone levels begin to drop, resulting in decreased muscle mass, increased fat, and a reduced sex drive.

Case Study

The physiological development of a male starts when a sperm with a Y chromosome fertilizes an egg. More male than female pregnancies occur, but because male fetuses are weaker, a greater number of miscarriages result. Also, more male infants die than do female infants.

Socioeconomic status of the mother determines whether prenatal care is received, appropriate prenatal and postnatal nutrition is available, and medical help is sought. If the mother smokes, drinks, or abuses drugs during pregnancy, the fetus can be adversely affected.

A man’s physiology is altered during puberty. The increased testosterone levels result in greater muscularity and a slimmer body. But testosterone also causes increased aggression.

Male gender roles are often hard for many men to uphold and can result in unhealthy behaviors. Repression of emotions also results in increased stress.

Sociocultural Factors

Sociocultural factors interact with biological factors to influence health.

• • Religion may affect the decision as to whether to circumcise the penis.

• • The cultural bias allowing men to be sexually permissive can compromise a man’s sexual health and wellness.

• • Ethnic heritage influences health; for example, African American males tend to have higher levels of stress and heart disease than white males.

• • Media and ads portray the ideal man with extreme muscularity, achievable only with tremendous work and, in many cases, illegal steroids.

• • Family, neighbors, and friends often reinforce gender stereotypes.

• • Behavior proscribed by society as illegal can influence health; for instance, a man can compromise his health by using anabolic steroids.

Psychological Factors

Biological and sociocultural factors combine to influence psychological factors.

• • Body image and self-concept are enhanced for many men through exercise and competitive sports.

• • In men who suppress their emotions, increased levels of stress can result.

• • Learned attitudes and behaviors about gender roles can lead to unhealthy lifestyles for men.

Summary

• • The male external genitals consist of the penis and the scrotum. The penis contains the urethra, through which urine and the ejaculate is omitted; the scrotum houses the testes.

• • Surgical removal of the foreskin (prepuce) is called circumcision. Over the years there have been differing views on the necessity for circumcision. In some cultures and religions, circumcision is recommended and, therefore, frequently performed.

• • The male internal genitals contain numerous structures. The urethra is the tube through which the ejaculate is ejected. The corpora cavernosa and corpus spongiosum fill with blood during sexual arousal, resulting in erection of the penis. Sperm are produced in the seminiferous tubules in the testes, stored in the epididymus, and travel out of the testes through the vasa efferentia.

• • The ejaculate consists of secretions from the prostate gland, the seminal vesicles, and sperm. It travels through the vas deferens to the urethra, where it is eventually ejected through the meatus of the penis.

• • During puberty, boys become capable of reproduction. This is a result of increased secretion of androgens, followed by the development of secondary sex characteristics. Males are not capable of reproduction before puberty because the prostate and seminal vesicles are not functional until they are activated by the increased production of testosterone that occurs during puberty.

• • Males are susceptible to a variety of reproductive system illnesses and conditions. Among these are breast cancer, inflammation of the prostate (prostatitis), enlargement of the prostate (benign prostatic hyperplasia), and prostate cancer.

• • Males should regularly care for their reproductive systems. These measures include screenings as appropriate, medical examinations by healthcare providers, and behaviors to prevent illnesses and diseases (for example, eating a nutritional diet, maintaining the recommended weight, exercising regularly, and adjusting the bicycle seat if one is a bicycle rider).

Discussion Questions

1.

Name and describe the parts of the male reproductive system, including external and internal genitalia.

2.

Explain how the increase and decrease of testosterone level affect the male reproductive system, including physiological and psychological effects.

3.

Describe the self-care and preventive practices that a man should use to ensure his sexual health.

Application Questions

Reread the story that opens the chapter and answer the following questions.

1.

The phrase “Most men think with their penis” clearly derives from the belief that hormones (physiology) control the man, and not vice versa. Do you believe this is correct? Or do sociocultural and psychological factors help balance a man’s thinking?

2.

The notion of penis size has generally been shown in research to be of little importance to women. Why does size continue to be a matter of jokes and of apprehension among men?

3.

Can the male concern with penis size be compared to a woman’s concern about her breast size? (After all, more than 100,000 women have breast enhancements each year.) If men could get relatively safe penis-enlargement surgery, do you believe that many would?

Critical Thinking Questions

1.

In many schools throughout the country, sexuality education classes mention the concept of menstruation in a mixed-gender group. But the real discussion of menstruation occurs only in the follow-up “girls only” groupings. Consider whether boys should be taught about menstruation. Without factual knowledge, how can boys comprehend the physical and emotional issues surrounding menstruation? How can they be prepared for safer sexual practices during menstruation if they have not learned about it? Finally, how would you explain menstruation to a group of fifth-grade boys?

Critical Thinking Case

Dad has not been feeling like himself lately. He is unusually tense and easy to upset. It may be due to his lack of sleep. He goes to bed at the same time he always has, but he wakes up often in the middle of the night to urinate. When you ask him about it, he says that he really does not excrete a great deal of urine, just enough to relieve the feeling of having to urinate. As you try to help Dad, answer the following questions.

1.

What are some possible causes of Dad’s waking up often in the middle of the night to urinate?

2.

What would you suggest Dad do about his dilemma? How could you help facilitate his taking this action?

3.

What other reproductive system health issues would you expect Dad to encounter as he gets older? What can he do to prevent or postpone the occurrence of these conditions? What can he do to respond to them as they arise?

Exploring Personal Dimensions

For Men Only

Taking charge of self-care and prevention greatly increases your chances of achieving sexual health and wellness. For the following statements, circle YES or NO. Then fill in the dates to help you keep track of your self-care activities.

Suggested Readings

Bostwick, D. G., Crawford, E. D., Roach III, M., & Higano, C. (eds.). American Cancer Society’s complete guide to prostate cancer. Atlanta, GA: American Cancer Society, 2004.

Bubley, G. J., & Conkling, W. What your doctor may not tell you about prostate cancer: The breakthrough information and treatments that can help save your life. New York: Warner Books, 2005.

Danoff, D. S. Penis power: The ultimate guide to male sexual health. Bloomington, IN: Author House, 2011.

Fisch, H., & Braun, S. The male biological clock: The startling news about aging, sexuality, and fertility in men. New York: Free Press, 2004.

McCarthy, B. W., & Metz, M. E. Men’s sexual health: Fitness for satisfying sex. New York: Routledge, 2007.

Peate, I. Men’s sexual health. Chichester, UK: Whurr Publishers, 2003.

Scardino, P. T., & Kelman, J. Dr. Peter Scardino’s prostate book: The complete guide to overcoming prostate cancer, prostatitis, and BPH. North Stratford, NH: Avery Publishing Group, 2005.

Taguchi, Y., & Weisbord, M. (ed.). Private parts: An owner’s guide to the male anatomy. Toronto, Canada: McClelland & Stewart/Tundra Books, 2003.

Vergel, N. Testosterone: A man’s guide. Newburg, PA: Milestones Publishing, 2010.

Web Resources

For links to the websites below, visit go.jblearning.com/dimensions5e and click on Resource Links.

Male Reproductive System

www.training.seer.cancer.gov/anatomy/reproductive/male

Diagram of the male reproductive system with links providing more information. Links include testes, duct system, accessory glands, penis, and male sexual response and hormonal control.

National Cancer Institute

www.cancer.gov

A federal government website providing information about cancer, including prostate and testicular cancers. Includes links to cancer topics, clinical trials, cancer statistics, research and funding, and current news pertaining to cancer.

American Cancer Society

www.cancer.org

A resource for all matters pertaining to cancer, including prostate and testicular cancers. Includes links to types of cancers, making informed treatment decisions, statistics, resources, and recent news.

The Male Health Center

www.malehealthcenter.com

An Internet education site providing information about male health. Included is information about sexual dysfunction, male sexual health problems, sexually transmitted infections, sexual hormones, and sexual aging issues.

Men’s Health Network

www.menshealthnetwork.org

Men’s Health Network (MHN) is a nonprofit educational organization comprised of physicians, researchers, public health workers, individuals, and other health professionals. MHN is committed to improving the health and wellness of men through education campaigns, partnerships with retailers and other private entities, workplace health programs, data collection, and work with healthcare providers to provide better programs and funding for men’s health needs.

References

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American Academy of Pediatrics. Where we stand: Circumcision, 2011. Available: http://www.healthychildren.org/English/ages-stages/prenatal/decisions-to-make/pages/Where-We-Stand-Circumcision.aspx.

American Cancer Society. American Cancer Society updates prostate cancer screening guidelines, June 12, 1997.

American Cancer Society. Cancer facts & figures 2010, 2010.

Andriole, G. L., et al. Mortality results from a randomized prostate-cancer screening trial. New England Journal of Medicine, 360 (2009), 1310–1319.

Barber, K. R., et al. Differences between African American and Caucasian men participating in a community-based prostate cancer screening program. Journal of Community Health, 23 (1998), 441–451.

Brinton, L. A., Richesson, D. A., Gierach, G. L., Lacey, J. V., Park, Y., Hollenbeck, A. R., & Schatzkin, A. Prospective evaluation of risk factors for male breast cancer. Journal of the National Cancer Institute, 100 (2008), 1477–1481.

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Chan, E. C. Y., Vernon, S. W., O’Donnell, F. T., Ahn, C., Greisinger, A., & Aga, D. W. Informed consent for cancer screening with prostate-specific antigen: How well are men getting the message? American Journal of Public Health, 93 (2003), 779–785.

Delvin, D., & Webber, C. Facts about penis size. Net Doctor, 2008. Available: http://www.netdoctor.co.uk/sex_relationships/facts/penissize.htm.

Haffner, D. W., & Schwartz, P. What I’ve learned about sex. New York: Perigee Books, 1998.

Huang, V., Munarriz, R., & Goldstein, I. Bicycle riding and erectile dysfunction: An increase in interest (and concern). Journal of Sexual Medicine, 2 (2005), 594–595.

Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. Sexual behavior in the human male. Philadelphia: Saunders, 1948.

Lee, U. J., & Jones, J. S. Incidence of prostate cancer in male breast cancer patients: A risk factor for prostate cancer screening. Prostate Cancer and Prostatic Diseases (May 27, 2008).

Lowe, B. D., Schrader, S. M., & Breitenstein, M. J. Effect of bicycle saddle designs on the pressure to the perineum of the bicyclist. Medicine and Science in Sports and Exercise, 36 (2004), 1055–1062.

Marceau, L., Kleinman, K., Goldstein, I., & McKinlay, J. Does bicycling contribute to the risk of erectile dysfunction? Results from the Massachusetts Male Aging Study (MMAS). International Journal of Impotence Research, 13 (2001), 298–302.

Masters, W. H., Johnson, V. E., & Kolodny, R. C. Human sexuality. Boston: Little, Brown, 1982.

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National Kidney and Urological Diseases Information Clearinghouse. Urinary incontinence in men. Bethesda, MD: Author, 2007. Available: http://kidney.niddk.nih.gov/kudiseases/pubs/uimen/#kegel.

Rovner, S. A reversal on circumcision. Washington Post Health (May 15, 1990).

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Savage, D. “Conscience” rule for doctors may spark abortion controversy. Los Angeles Times (December 2, 2008).

Schrader, S. M., Breitenstein, M. J., & Lowe, B. D. Cutting off the nose to save the penis. Journal of Sexual Medicine, 5 (2008), 1932–1940.

Schroder, F. H., et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine, 360 (2009), 1320–1328.

Smith, G. L., Greenup, R., & Takafuji, E. T. Circumcision as a risk factor for urethritis in racial groups. American Journal of Public Health, 77 (1987), 452–454.

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U.S. Preventive Task Force. Screening for testicular cancer, 2010. Available: http://www.uspreventiveservicestaskforce.org/uspstfl0/testicular/testicuprs.htm.

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