Female orgasms and a 'rule of thumb

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'C-V distance' may be a factor in how easily a woman has an orgasm.
By Regina Nuzzo, Special to The Times
February 11, 2008
During intercourse, the female orgasm can be elusive. What frustrated woman hasn't wondered: Am I simply, um, put together differently than other women?

Kim Wallen, professor of psychology and behavioral neuroendocrinology at Emory University, is busy doing the math to find out. And, yes, he says, simple physiology may have a lot to do with orgasm ease -- specifically, how far a woman's clitoris lies from her vagina.

That number might predict how easily a woman can experience orgasms from penile stimulation alone -- without help from fingers, toys or tongue -- during sexual intercourse.

In fact, there's even an easy "rule of thumb," Wallen says: Clitoris-vagina distances less than 2.5 cm -- that's roughly from the tip of your thumb to your first knuckle -- tend to yield reliable orgasms during sex. More than a thumb's length? Regular intercourse alone typically might not do the trick.

Wallen is not the first to check into this "C-V distance." In the 1920s, Princess Marie Bonaparte, a French psychoanalyst and close friend of Sigmund Freud, grew fed up with her own lack of orgasmic response. In her professional practice, she saw plenty of patients with the same complaint ("frigidity," in the parlance of the day).

She blamed physiology, not psyche.

Bonaparte collected C-V and orgasm data from her patients and in 1924 delicately published her observations under a pseudonym. (She also persuaded an Austrian surgeon to experiment on her, by cutting around her clitoris and stretching it closer to her vagina -- with disappointing results.)

Recently, Wallen dug up Bonaparte's measurements and analyzed them with modern statistical techniques. Sure enough, he found a striking correlation. Now he is hoping to do his own measurement study.

Preliminary work has revealed that only about 7% of women always have orgasms with sex alone, he says, while 27% say they never do. The current research hold-up: developing a reliable, at-home technique for measuring C-V distance, especially one that can deal with stretchy skin.

Women with a large C-V distance should not be discouraged, Wallen says. "Personally, I don't think the inability to experience no-hands, penis-only intercourse with orgasm says anything about a happy sex life," he says. "Maybe it could allow couples to be a bit more inventive in how they have sex."

He acknowledges that the measure might become one more standard women feel they need to live up to, like breast size. "People would ask, 'Is your distance really small?' "

Drugs' double-edged sword

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A young man reportedly taking the antidepressant Prozac has a history of significant psychiatric troubles, including self-cutting, obsessive thoughts and anxiety. But among the 27-year-old's current teachers and acquaintances, he has a reputation as a caring, dependable friend and a highly motivated student.

Surely, say mental health professionals, this recovery was brought about by Prozac.

The same young man, saying the drug makes him feel "like a zombie," abruptly discontinues his antidepressant and begins to behave erratically. About three weeks later, he steps from behind a curtain in a classroom at his alma mater and begins shooting, killing five students before turning the gun on himself.

Just as surely, say critics of antidepressants' widespread use, this unraveling was brought about by Prozac.

Steven Kazmierczak's bolt-from-the-blue shooting spree on Feb. 14 reignited a long-running debate over the benefits and risks of antidepressants -- taking them and discontinuing them.

"It's sad to watch this," says Ann Blake Tracy, executive director of the International Coalition for Drug Awareness and co-founder of a website, SSRI stories.com, that catalogs violent crimes like Kazmierczak's and links them to psychiatric drug use. "You find suicide, murder, rape, arson" -- all caused by drugs such as Prozac, she says. "How did they convince us that this is therapeutic?"

Most in the psychiatric profession would counter that antidepressants overwhelmingly save lives, and salvage those hobbled by sadness and anxiety. They doubt that coming off these drugs -- especially Prozac, which Kazmierczak was reported to have taken -- led the Illinois gunman to kill.

And they fret that depressed patients who believe the charges of critics like Tracy will turn their backs on medicine that can work wonders if taken -- and stopped -- correctly.

"When a story like this is brewing, people think, 'If this medication can possibly be related to a bad outcome, I'd better get off it now,' " says UCLA psychiatrist Andrew Leuchter. "We're talking about millions and millions of people who've been treated successfully with these drugs and stopped treatment without any kind of dramatic changes of behavior."

At the center of the latest tempest over psychotropic drugs is a long-recognized phenomenon called Antidepressant Discontinuation Syndrome. First identified in psychiatric journals in the late 1990s, the condition is an assortment of symptoms that can plague patients for several weeks and, in a few cases on medical record, months after coming off a wide range of antidepressants. They include dizziness, headache, fatigue, changes in sleep patterns and appetite, vivid or disturbing dreams, agitation and anxiety. Some patients experience tingling or "electric zap" sensations passing through their extremities or head and, in rare cases, spasmodic jerking in the extremities, especially while sleeping.

Though the symptoms of the syndrome can be distressing for patients, many psychiatrists insist that they are rarely dangerous and can be managed by weaning a patient off antidepressant medication very slowly. As patients taper off their meds, however, they and their doctors must assess whether symptoms such as anxiety and agitation, which may affect a patient's behavior and reactions, are a sign of the syndrome or a recurrence of the illness that led to the medication in the first place.

It's not always an easy call, says Dr. Richard Shelton of Vanderbilt University, a leading researcher on antidepressants and their effects.



Lightning rod for debate

Twenty years after Prozac appeared on the U.S. landscape, roughly 10% of American women and 4% of American men take an antidepressant regularly. The selective serotonin reuptake inhibitors (SSRIs) and their close cousins have revolutionized attitudes toward mental illness and its medication in this country. But they remain a lightning rod for controversy.

The role that antidepressants played in Kazmierczak's violent end probably will never be clear. Did Prozac, which Kazmierczak's girlfriend, Jessica Baty, said he had been on but had recently discontinued, help keep the 27-year-old's mental illness in check and, when halted, allow it to roar back? Or did it distort his personality, contort his thoughts and, when abandoned, cause a chemical storm in Kazmierczak's brain that spawned a fury of aggression?

The weight of clinical observations and psychiatric research favors the view that antidepressants helped Kazmierczak until the time he abandoned them. But skeptics charge that antidepressants may have caused or contributed to Kazmierczak's spasm of violence. And mental health experts acknowledge they cannot rule out that possibility.

"You're going to get some unpredictable reactions if you have millions of people taking them and going off. The potential for violent behavior, suicide and particularly impulsive suicide exists," says Shelton, a professor of psychiatry and psychopharmacology. "And the sicker the person is coming in the front door, the more likely they are to have a bad crash when they go off. We do see these extreme reactions."

In a category of drugs so widely used, how could potentially dangerous side effects remain a matter of uncertainty? For several reasons, experts say.

For starters, individuals' responses to antidepressants, though mostly predictable, can vary widely. Psychiatric diagnosis and medication decisions are imprecise and can be disastrously wrong; in cases where a patient with bipolar disorder is misdiagnosed and put on antidepressants, for example, the medicine has been found in some cases to bring on an episode of mania.

And, as the Food and Drug Administration acknowledged in 2007 when it warned of a heightened risk of suicide and suicidal thoughts among young patients starting on many of these drugs, 20 years after their arrival on the scene a full picture of antidepressants' side effects may still be emerging.

Research on animals points strongly to the possibility of heightened violence with the abrupt withdrawal of most antidepressants. Studies using cats and rodents have long shown that sudden declines in the neurotransmitter serotonin (the chemical that most antidepressants, in some fashion, make more available in the brain) will suppress an animal's natural caution and intensify its aggressive reactions toward other animals.

Though the human brain may have more powerful braking mechanisms than a cat's, the role of serotonin in inhibiting impulsive aggression is well established, says neuroscientist Allan Siegel of the University of Medicine and Dentistry of New Jersey, author of "The Neurobiology of Aggression and Rage."

It is expected to be several weeks before Kazmierczak's medical records and postmortem results are fully evaluated and made public. If they suggest that Kazmierczak's murderous act was linked to his abrupt discontinuance of an antidepressant, those findings may dismay the many patients who were not warned from the start of the risks they might face when going off such medicine.

Such findings could also be a sobering reminder to patients that these are not drugs to be dropped on a whim. Currently, an estimated half of patients who start on antidepressant therapy go off their medication in less than a year.

For medical professionals, the case of Steven Kazmierczak may hold other lessons: It could put physicians on alert for symptoms of Antidepressant Discontinuation Syndrome that lie at the extreme, including violence and suicide. It could underscore that when prescribing antidepressants, physicians need to alert patients that coming off these medications can be a bumpy road.

It may also remind physicians that they should take the same care to monitor a patient's state in the first several weeks off the medication as they do when a patient is just getting started.

According to a 2006 review article published in the journal Primary Psychiatry, the "untoward post-treatment effects" of the syndrome are believed to affect a majority of those who have taken antidepressants in the same class as Prozac for more than six weeks and then stopped. The unnerving symptoms can be particularly acute in cases where, as Kazmierczak is believed to have done, patients abruptly stop taking their medication.

The antidepressants venlafaxine (also marketed as Effexor) and paroxetine (also marketed as Paxil) are most often associated with pronounced discontinuation reactions, which, in these cases, are usually felt quickly -- within two to three days after a patient stops taking these drugs.

Such negative post-treatment effects are considered rare among patients taking Prozac, which Kazmierczak's girlfriend said he had been taking until about three weeks before the shooting. When the effects do happen, experts said they tend to be felt several weeks after fluoxetine, Prozac's chemical name, has been discontinued, because fluoxetine lingers in the body longer than venlafaxine or paroxetine do.

While acknowledging that there is little research to show which patients are most affected by discontinuation effects, Vanderbilt psychiatrist Shelton says he has observed that those who suffer from depression coupled with obsessive-compulsive disorder "seem to be prone to pretty significant reactions."

Shelton cautions that in cases where a patient's reaction to going off an antidepressant seems extreme, a physician should taper the dose "excruciatingly slowly." In Shelton's experience, he says, a gentle reduction of medicine can not only minimize discontinuation symptoms, but may make recurrence of depressive symptoms less likely.

"It's not a horse race. No one says you have to be off medications in three weeks or even three months," Shelton says.

In the war of words over antidepressants, this may be a point of rare consensus between those who believe in the power of antidepressants and those intent on raising alarms.

"As firm as I am on the dangers of these drugs, I'm afraid of withdrawal," says Tracy of the International Coalition for Drug Awareness. "Because if people quit, and don't know how to come off the right way, we're really going to be in trouble."

melissa.healy@latimes.com

Call him doctor 'Orgasmatron'

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Dr. Stuart Meloy stumbled upon an alternative -- and pleasurable -- use for an electrode stimulation device that treats pain.

By Regina Nuzzo, Special to The Times
February 11, 2008

Dr. Stuart Meloy never set out to study orgasms. It was an accident.

He was in the operating room one day in 1998, implanting electrodes into a patient's spine to treat her chronic leg pain. (The electrodes are connected to a device that fires impulses to the brain to block pain signals.) But when he turned on the power, "the patient suddenly let out something between a shriek and moan," says Meloy, an anesthesiologist and pain specialist in North Carolina.

Asked what was wrong, she replied, "You'll have to teach my husband how to do that."

Meloy moved the electrodes until he found the correct, pain-numbing position on the spine. "I went home, had a funny story to tell my wife," he says.

He almost left it at that.

But the next day, he told the story to some colleagues, and a gynecologist commented that one-third of his patients complain of orgasm dysfunction.

Might this, Meloy mused, potentially help such people?

He started a formal pilot study of the device, which is approved for use in treating bladder and pain problems, implanting it in the spines of 11 women, some of whom had never had an orgasm. The women, who were instructed to keep a record of all their sexual experiences, were allowed to use the device for nine days adlibitum.

Meloy's study, published in 2006 in the journal Neuromodulation, reported that 10 out of 11 of the patients felt pleasurable stimulation from the device, including increased vaginal lubrication. Five of the women had previously lost their ability to have orgasms; four regained it with the device. (The fifth never used her device during the nine-day trial because of work stress, she said.)

None of the five women who had never had an orgasm was able to experience one with the device, however. "They said it was pleasurable, but it wasn't sending them over the edge," Meloy says.

The experimental implant -- now trademarked by Meloy as the Orgasmatron after the orgasm-inducing cylinder in Woody Allen's 1973 movie "Sleeper" -- rests on the skin just above the belt line. Two electrodes snake into the space between the vertebrae and the spinal cord. A video-game-like remote control allows women (or their partners) to turn electrical pulses on and off and fiddle with timing and intensity.

Electrodes in the right place (determined partly by trial and error) seem to interact with various nerve networks, Meloy says, including nerves from the pelvis that enter the spinal highway near the tailbone. Stimulating those nerves shoots pleasure signals straight up to the part of the brain that processes information coming from the genitalia.

Women who have used the device say they feel as if their clitoris and vagina are actually being stimulated, to quite realistic effect. ("One woman asked me, 'Would it be considered adultery if I gave the remote control to someone other than my husband?' " Meloy says.)

Some volunteers also report fleeting episodes of clenched foot muscles, Meloy says, probably a result of electrical pulses leaving the spine and stimulating nearby motor nerves. (He wonders if the phenomenon might somehow be related to a common orgasm description: "My toes curled.")

And when the device's pulse intensity is cranked up to maximum, Meloy says, some women find their vaginal and rectal muscles squeezing rhythmically in time with the pulses, even before the orgasmic finale.

Meloy thinks that practice, or at least past experience, is key to success with the device. Without prior orgasm experiences, crucial neural pathways may never have been laid down, possibly explaining why women who'd never had orgasms did not experience one during the nine-day trial. Even with extra stimulation from the device, Meloy says, nine days may not have been enough time to build pathways up to full orgasmic strength.

And even the successful women in the trial lost their recovered orgasmic ability when the devices were removed. Meloy hopes that longer access to the device would let women practice their newfound skills and fortify neural pathways -- a sort of orgasmic neural rehabilitation.

Meloy says he has also implanted two impotent men with the device. Both volunteers were able to achieve an erection, he says, and reportedly had powerful ejaculations.

Meloy sees two potential male markets for the device. One includes men with erectile dysfunction who take nitrates for heart disease and therefore cannot take Viagra or similar medications, like Jack Nicholson's character in the film "Something's Gotta Give." The other might be recreational users, men interested in boosting their existing erections and ejaculations -- and willing to pay for elective surgery.

Design work is underway to get the cost of the procedure down to about $12,000 -- roughly the price of breast implants, Meloy says.

He plans to shrink the size of the internal processor to the size of two sticks of gum and the external processor to roughly the size of a belt pager, all while ensuring that the system is durable enough to withstand shear forces of typical use.

Before Food and Drug Administration approval could be granted and the device sent to market -- Meloy estimates that's probably still two or three years away -- the new design will need to be tested in another study, he says. But there will be no animal testing phase. "I don't know how to ask animals, 'Where do you feel the tingling?' or 'Do you want a cigarette?' "

A boost for women's low libido

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There's no approved treatment for the waning of sexual desire after menopause, but a gel is being tested.
By Janet Cromley, Los Angeles Times Staff Writer
February 11, 2008

Thanks to Viagra, Cialis and Levitra, men with erectile dysfunction can get on board the Food and Drug Administration-approved love train. But women who experience a different sexual problem -- sagging libido -- have been left at the station.

That may be changing.

BioSante Pharmaceuticals Inc. is testing the safety and effectiveness of LibiGel, a testosterone gel for women designed to combat declines in sexual arousal associated with menopause. There are currently no drugs available in the U.S. specifically approved for pumping up lackluster libido in women.

The Lincolnshire, Ill.,-based company is conducting two trials, comprising 1,000 women, to test the effectiveness of the gel, which is applied to the upper arm. The company will also test the gel's safety in a trial of as many as 3,100 women using LibiGel or a placebo.

If the trials go well, the drug could be available by prescription by 2011, says BioSante chief executive Stephen Simes.

A testosterone gel for menopausal women makes sense medically, says Dr. Richard Paulson, professor of reproductive medicine and chief of reproductive endocrinology at USC's Keck School of Medicine.

Both men and women produce the female hormone estradiol and the male hormone testosterone, but in different quantities. When women go through menopause, they lose almost all of their estradiol production and most of their testosterone production. Estrogen (either taken orally or topically applied) helps keep the vaginal tissue strong and elastic, but it doesn't enhance libido.

A testosterone gel, Paulsen says, could restore libido and reestablish the pre-menopausal balance between testosterone and estradiol. It could be especially beneficial to women who have had their ovaries surgically removed and lose even the small amounts of testosterone that ovaries produce after menopause. This population "is particularly susceptible to symptoms attributable to the loss of hormone production, such as hot flashes and loss of libido," he says.

Currently, the only option postmenopausal women have for boosting testosterone is off-label use of products developed for men, says Sheryl Kingsberg, chief of Behavioral Medicine at University Hospitals Case Medical Center in Cleveland, Ohio. "We know that it works -- not for everybody -- but it works," she says. "And we know that about 20% of all prescriptions for testosterone are for women."

But safety, particularly the possibility that testosterone could increase the risk of breast cancer, is still a concern. "We haven't seen serious adverse effects" from use, says Kingsberg, a psychologist and sex researcher, "but we need more data."

The first LibiGel trial was launched in December 2006. About 500 healthy women ages 30 to 65 across the U.S. and Canada who had had their ovaries removed and reported distress over low libido applied LibiGel or a placebo for 24 weeks. Using diaries and questionnaires as measurements, the women documented quantity and quality of sexual events, including intercourse, oral sex and masturbation.

Following treatment, the women using LibiGel reported a significantly increased number of satisfying sexual events compared with baseline measures and compared with the placebo group. Participants reported no serious adverse effects. A second, identical trial will begin in the spring to ensure that the findings can be replicated.

The data have been presented at meetings of the International Society for the Study of Women's Sexual Health and North American Menopause Society.

A third, 12-month study will track cardiovascular events, such as heart attack and stroke, among women taking the drug, and compare them with those of a control group. Participants will be surgically or naturally menopausal women at least 50 years of age, with at least one cardiovascular risk factor, such as hypertension or diabetes.

"The FDA is asking us to study the safety in potentially a higher-risk population in order to prove that, in fact, testosterone is safe for all women," Simes says.

The study will also track the women for breast cancer for an additional four years.

Side effects associated with excessive testosterone in women include oily skin and hair growth in undesirable places, including the face and chest.

Paulson cautions that anyone hoping for an elixir of love is in for a disappointment. "Western society is replete with stories of magical potions that will cause women to become sexually ravenous," he says. "These stories of course are nonsense."

Human sexuality is complex, he adds, and testosterone level is only a small part of the overall picture. "For people who think that they are going to be able to sneak it onto their date's arm while she's not looking -- they should forget it."

Female orgasms and a 'rule of thumb

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'C-V distance' may be a factor in how easily a woman has an orgasm.
By Regina Nuzzo, Special to The Times
February 11, 2008
During intercourse, the female orgasm can be elusive. What frustrated woman hasn't wondered: Am I simply, um, put together differently than other women?

Kim Wallen, professor of psychology and behavioral neuroendocrinology at Emory University, is busy doing the math to find out. And, yes, he says, simple physiology may have a lot to do with orgasm ease -- specifically, how far a woman's clitoris lies from her vagina.

That number might predict how easily a woman can experience orgasms from penile stimulation alone -- without help from fingers, toys or tongue -- during sexual intercourse.

In fact, there's even an easy "rule of thumb," Wallen says: Clitoris-vagina distances less than 2.5 cm -- that's roughly from the tip of your thumb to your first knuckle -- tend to yield reliable orgasms during sex. More than a thumb's length? Regular intercourse alone typically might not do the trick.

Wallen is not the first to check into this "C-V distance." In the 1920s, Princess Marie Bonaparte, a French psychoanalyst and close friend of Sigmund Freud, grew fed up with her own lack of orgasmic response. In her professional practice, she saw plenty of patients with the same complaint ("frigidity," in the parlance of the day).

She blamed physiology, not psyche.

Bonaparte collected C-V and orgasm data from her patients and in 1924 delicately published her observations under a pseudonym. (She also persuaded an Austrian surgeon to experiment on her, by cutting around her clitoris and stretching it closer to her vagina -- with disappointing results.)

Recently, Wallen dug up Bonaparte's measurements and analyzed them with modern statistical techniques. Sure enough, he found a striking correlation. Now he is hoping to do his own measurement study.

Preliminary work has revealed that only about 7% of women always have orgasms with sex alone, he says, while 27% say they never do. The current research hold-up: developing a reliable, at-home technique for measuring C-V distance, especially one that can deal with stretchy skin.

Women with a large C-V distance should not be discouraged, Wallen says. "Personally, I don't think the inability to experience no-hands, penis-only intercourse with orgasm says anything about a happy sex life," he says. "Maybe it could allow couples to be a bit more inventive in how they have sex."

He acknowledges that the measure might become one more standard women feel they need to live up to, like breast size. "People would ask, 'Is your distance really small?' "