Libido -- Hormones
- Do you know of a physician or practitioner locally that prescribes bioidentical rather than synthetic hormones?
Yes, we work closely with Dr. Mark Binkley, a compounding pharmacist who is familiar with bioidentical hormones. He is located at 329 21st Ave North, Suite 3, Nashville, TN 37203. Phone 615-383-3784. www.rxcompounder.com. Dr. Allan Redash is an OB/Gyn in Gallatin that also uses bioidentical hormones and he works closely with Mark Binkley. He is located at 590 Hartsville Pike, Gallatin, TN 37066. Phone 615-451-9810.
- Does testosterone have negative effects? If so, can you please tell me more?
Yes, testosterone, just like many medications and hormones, can have adverse effects. These include weight gain, acne, hair loss, facial hair growth, deepening of voice, menstrual irregularities, and mood change. It certainly depends on the route of administration, type of testosterone, and dosage. For instance, adverse effects from oral testosterone differ from those related to injectable or topical testosterone. Proper monitoring and management of testosterone replacement limits these effects.
- How do you personally feel about herbal medications and holistic remedies?
I am a big fan of alternative therapies including herbal and homeopathic preparations, compounded individualized preparations, acupuncture, physical therapy, aromatherapy, hypnotherapy, etc. Traditional western medicine works well for many conditions, but it is not always the best answer for every patient. At WISH, we create an individualized treatment plan for each patient, which incorporates both traditional western philosophy and alternative therapies. We have had wonderful success with both options.
- What are the treatment options for increasing libido? Is there a pill I can take or shot I can receive?
Unfortunately, there is no “quick fix” for low libido in women. Unlike men, women’s model of desire, arousal, and orgasm is complicated and cannot be treated with a simple pill. Fortunately, there are many treatments for low libido in women. The trick is to properly identify the root cause. At WISH, we utilize a variety of treatments including hormone therapy, vitamin and mineral supplements, herbs, arousal fluids, clitoral suction devices, acupuncture, physical therapy, sex therapy, and arousal techniques, just to name a few.
- Should I have a blood test to evaluate my hormone levels? I have reached menopause and have a lack of sexual desire and delayed orgasm? Will this help in my treatment?
I often check extensive hormone levels in women. For instance, there are many different forms of testosterone in a woman’s system, and it is necessary to check all of them in order to determine a proper treatment plan. Ironically, some women have abnormal hormone levels, such as low testosterone, yet they report strong libidos, while other women may have normal hormone levels but low libido. So hormone testing is not the only piece of the puzzle, but it can certainly help in creating an individualized treatment plan.
- I feel like I have 80% of the conditions listed on your website and as discussed in your recent seminar. Is there one specific remedy for me or should I expect multiple treatments for multiple problems?
Every patient is different and treatment plans vary. Low desire is different from lack of arousal which is different from inability to have orgasms. Pain with intercourse encompasses multiple diagnoses that are treated in a variety of ways. What I typically do is identify the most distressing problem first, then work through the list. Most often, if a patient is experiencing pain, I recommend dealing with that first, because no matter what, desire is not going to be present if a woman anticipates pain with intercourse.
- Is it safe for a woman to take Viagra?
Pfizer (the company that markets Viagra) discontinued studies on Viagra in women because there were no obvious benefits. But other recent research has shown that women with normal hormone levels can benefit from the use of such medications as Viagra. More research is needed to confirm this. At this time there are no FDA approved medications for female sexual dysfunction.
- I usually only experience desire right before my monthly cycle...why?
Hormones such as estrogen, progesterone, and testosterone fluctuate during the menstrual cycle. Some women are sensitive to this and oftentimes feel a surge in libido right before ovulation and right before menstruation. This is completely normal and healthy. Women are more likely to experience this if their menstrual cycles occur on a regular basis.
- Where do I start in seeking help for my total lack of desire?
WISH! While there are many clinicians capable of treating low desire, we at WISH provide a comprehensive workup specific to female sexual issues. This helps to identify the best treatment plan for you. This often includes referrals to other sources such as counseling, physical therapy, acupuncture, and local clinicians.
- Is there really a peak sexual age for women, or is this a myth?
This is an age-old question. I can tell you that every woman is different and there is no “normal” among multiple women, only “normal” within yourself. Some women notice peaks and troughs in their libido throughout life which can be attributed to hormone fluctuations, lifestyle changes, physical health, and psychological health. I can tell you that women who experience arousal on a regular basis maintain healthy libidos and prevent atrophic vulvar changes more often than women who rarely or never experience arousal. I can also tell you that I have women who are 80+ years old who still experience regular, healthy and satisfying sex lives!
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- Does WISH accept my insurance?
As a courtesy, we accept all insurances and will be happy to file a claim for you. However, as with any medical expense, any unpaid deductibles and non-covered procedures will become the patient’s financial responsibility. We have a caring and understanding staff that will assist you in a payment schedule to suit your budget should the need arise.
- Will Medicare and other insurances cover evaluation and treatment of female sexual dysfunction?
At this time, we have no defined measure of evaluating what your insurance will or will not cover. Keep in mind that even male sexual dysfunction procedures and diagnoses are often not covered at 100%. Our caring staff will assist you in designing a payment schedule to suit your budget should the need arise.
- Are homeopathic medications covered by insurance? If not, why?
The Food and Drug Administration (FDA) does not recognize most homeopathic remedies and insurances tend to follow suit. The FDA requires all medications and therapies undergo strict research and validation in order to be listed as a “preferred medication”. Most homeopathic therapies do not fall under those guidelines. Rest assured that Wish will not recommend any homeopathic remedy that has not be tested.
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- How can it be that I can achieve orgasm while dreaming, but rarely with my partner during lovemaking?
There is a strong psychological component that coincides with female sexual arousal. Many women experience spontaneous orgasms in their sleep simply because they are in a full state of relaxation and thoughts/fantasies occur freely during sleep that may not normally take place in daily life. During lovemaking, there are many factors that can inhibit this psychological response that is necessary for orgasm including fear of rejection, non-stimulating sexual techniques, pain, embarrassment and concern for unwanted pregnancy.
- Is it normal if I do not reach orgasm every time I am in a sexual situation?
Absolutely. As stated before, there is no “normal” when it comes to the female sexual response. Women are not designed so that orgasm is necessary for procreation. Some women report that orgasm is not their ultimate goal when it comes to sex. The emotional intimacy and closeness that occurs is more important. If orgasm is difficult to attain and it causes personal distresses, there are some things to ask yourself. Are you orgasmic with self-stimulation, oral sex, manual stimulation, or any other form of stimulation? If so, then you simply need to find sexual positions that stimulate your most sensitive areas. You can also increase time spent in foreplay and/or change up your sexual routine with toys and fantasies in order to heighten your level of sexual excitement before intercourse takes place. If you have difficulty enjoying sex altogether with your current partner or if you have an aversion to sex with your partner, that is a whole other question. You may have issues in your relationship that you are not addressing that may be inhibiting your ability to enjoy sex with that person.
- Is there such a phenomenon as multiple orgasms?
Women have the wonderful ability to have multiple orgasms, contrary to our male counterparts. Men have a component of their sexual arousal cycle called the refractory period, where they must rest following orgasm before experiencing stimulation again. Women, on the other hand, do not have a refractory period and can experience multiple fulfilling orgasms back-to-back.
- Why can I only reach orgasm with clitoral stimulation but not with vaginal penetration?
The clitoris has many nerve endings in a very small area. The vagina, on the other hand, has many less nerve endings per area comparable to the clitoris. For most women, clitoral stimulation is much more intense than vaginal penetration and orgasm is more easily accomplished via clitoral stimulation. There are techniques that you can use to either stimulate the clitoris during intercourse, or learn other areas of the vagina and vulva that cause intense arousal. I encourage you to experiment...women are not all the same. What turns one woman on may have no effect on another woman.
- Is it “abnormal” for me NOT to masturbate or have no desire to do so?
Absolutely not. There is no right or wrong way to enjoy your sexuality and if you have no interest in masturbation, then there is no reason to worry about it. Assuming your lack of interest in self-stimulation is simply that, I still encourage you to perform routine self-assessments. The vaginal tissue is susceptible to many changes throughout life and by being familiar with your vulva and vagina, you can help detect unwanted changes early. Now, if you have an aversion to self-stimulation due to your upbringing or a traumatic childhood experience, that is a different story. In that situation, it is helpful to seek counsel from a psychologist who can talk through your aversion(s).
- Can birth control actually affect sexual desire? If so, is this chemical and is it permanent?
Recent research has identified a link between oral hormonal birth control and an increase in a hormone called sex hormone binding globulin (SHBG) that remains elevated even after discontinuation of the birth control. SHBG binds testosterone in the blood stream, rendering it useless to the body. In this case, a woman may have “normal” testosterone levels, but because of the elevated SHBG, a low libido. The thing to remember is that all women are different. Not all women notice a lessening in libido in response to birth control and testosterone is only one part of the complicated female sexual response. I do not recommend that women stop taking oral hormonal birth control simply because of this finding, but notify your prescribing clinician if you have any change in your libido.
- Do you think masturbation with a vibrator to orgasm makes it easier or more difficult to achieve orgasm during foreplay and/or intercourse?
Achieving orgasm with a vibrator is oftentimes much easier than achieving orgasm through intercourse simply because vibrators are designed to provide intense stimulation to the most sensitive part of a woman’s genitals, the clitoris.
- What is the difference between “clitoral orgasm” and “G-spot orgasm”? How do I locate my G-spot?
The G-spot is a controversial area believed to be located on the anterior portion of the vagina (facing the abdomen) about 1-2 inches inside the vagina. Unfortunately, this area has not been well studied and the few published studies out there conflict. Currently, it is believed that either internal clitoral tissue and/or the urethral tissue become engorged and aroused when stimulated directly. These orgasms tend to be more robust in nature comparable to clitoral orgasms and often provide the opportunity for multiple orgasms. Positions that enhance stimulation of the G-spot include rear entry position or “doggy style” and woman-on-top facing toward the man’s feet.
- Is it normal for me to achieve orgasm from a non-sexual stimuli, such as from the jets in my hot tub? It is very therapeutic and I don’t need to think of my husband or another person to achieve it.
It is very normal and very healthy for women to achieve orgasm through a multitude of different means. Intense jets of water such as those in hot tubs can provide significant stimulation similar to that of manual stimulation. Be careful of hot tubs and baths, though. Not only can chlorine irritate sensitive vulvar tissue, but bacteria from your skin can enter your vagina via the water and result in vaginal infections.
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- Can you explain “vulvar atrophy”? As I understand it, it is thinning of the vulvar tissues that can cause loss of elasticity and very painful sex, as well as vaginal dryness.
Vulvar atrophy is a term that refers to the loss of vulvar tissue integrity associated with low estrogen levels. The tissue often becomes dry, irritated and loses it’s natural elasticity. This most commonly occurs during and after menopause, but can also occur due to other reasons such as medication use, hysterectomy, medical disorders, chemotherapy, breastfeeding, lack of regular arousal, and birth control use. When this occurs, regardless of the cause, sex oftentimes becomes extremely difficult and painful due to the lack of give in the vagina. Small microscopic tears can occur at the opening of the vagina that become even more painful. There are many ways to treat this symptom, depending on the cause. Women can prevent this from happening by experiencing arousal regularly.
- I had a hysterectomy 23 years ago. I have been on Estratest since that time. I have experienced vaginal dryness and began using Estrace cream for that. It does help but hasn’t solved my problem. Do you recommend adding K-Y Jelly to my regimen? If not, what can you advise?
Many women can tolerate such things as K-Y Jelly for use as a lubricant, but I do not recommend it. K-Y jelly and many other marketed “personal lubricants” contain known vulvar irritants such as glycerin, petroleum, preservatives, sucrose, etc. I recommend products that are free from these irritants such as Luvin Lube and Zestra. Also, Estrace is a wonderful lubricant itself. If massaged into the bottom of the opening of the vagina about 15 minutes before intercourse, it will help the tissue become more elastic and produce natural lubrication.
- Do homeopathic therapies, such as herbal supplements aid in decreased desire after menopause. If so, can you recommend some to me?
There are many supplements on the market that claim to “increase desire”. A favorite of mine is ArginMax, which is a dietary supplement taken twice daily. It has been studied and shown to help aid the body’s sexual responsiveness. Two of the ingredients, Ginseng and L-Arginine are believed to be the main ingredients that promote this response. Be aware that L-Arginine can potentiate herpes outbreaks, so if you are susceptible to outbreaks, do not take this supplement.
- After menopause, is there hope of attaining the level of desire I used to have?
Postmenopausal loss of desire is often attributed to hormonal changes but it can also be related to stress, significant life changes, partner sexual difficulties, etc. Although I can never promise an outcome, I’ve had many women regain the libido that they remember in their 20’s. Some women even report an increase in libido following menopause which can be attributed to more time available to spend with a partner, lack of pregnancy concern, and satisfaction with life accomplishments.
- Since menopause, I can reach orgasm but before full completion, I “lose it”...this is very frustrating – can you recommend something?
This sounds like it may have a psychological component to it. I hear this complaint a lot...even from young women. These women report that they have spontaneous thoughts/desire for sexual stimulation and they become sexually aroused easily, but orgasm becomes (or always has been) very difficult to attain. Oftentimes this is related to such things as moral/ethical concerns related to sexual practices, embarrassment over looks/body, stress, lack of communication with partner, or even issues related to the partner such as premature ejaculation and erectile dysfunction. I recommend that you think through recent sexual experiences. First of all, are you able to attain orgasm by yourself, just not with your partner? If so, then there is nothing physically wrong with you. Ask yourself...are you completely comfortable with your body and with your spouse? Does anything occur that causes you to become uncomfortable? Are you thinking about other things while having sex/self-stimulating such as the kids, cooking, work, etc? Does your partner know what turns you on? Does your partner have difficulty maintaining an erection or with ejaculating soon after beginning sexual activity? If you do not think any of these questions apply to you or if you are incapable of having an orgasm even with self-stimulation, then I would recommend seeing a sexual health clinician to discuss this issue further.
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- I maintain decent arousal throughout sexual activity but half way through, I become dry. What can I do for this?
Vaginal dryness can occur for many reasons. It is often believed that this only occurs after menopause, but actually, women of all ages complain of this issue. Some reasons for this are low hormone levels, medication use, vaginal infections, stress, lack of appropriate stimulation, pain, birth control use, prolonged sexual intercourse and certain medical conditions. I recommend that women who experience dryness during sex use non-irritating lubricants such as Zestra or Luvin Lube. It is important to see a clinician about this to determine the underlying cause, which can often be treated. Whatever the cause, chronic vaginal dryness in the presence of sexual intercourse predisposes a woman to irritation, inflammation and pain.
- Does your office perform annual pap smears and STD screenings?
WISH does not perform annual gynecologic examinations. Rather, we specialize in female sexual dysfunction. Sometimes, tests run at an annual exam coincide with diagnostic tests needed during a sexual health workup. But generally we recommend that you continue to see an OB/Gyn clinician regularly.
- In your seminar, you discussed smoking and the effects on sexual arousal. Does that pertain to female smokers only or should I be concerned about second hand smoke as well?
Second hand smoking has been shown to cause just as many (if not more) physical problems as direct smoking. Theoretically, if you are subjected to continuous second hand smoke, for example, if your spouse smokes regularly, then you are just as likely to experience difficulties with sexual arousal as if you were smoking the cigarettes yourself.
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- How do I improve problems with communication in the bedroom?
I recommend that you discuss your concerns with your partner in a neutral environment and in a non-confrontational manner, ie: Do not bring sensitive issues up while in the bedroom and do not blame or talk down to your partner. Try scheduling time to talk and begin your conversation with “I really love you and I value our sexual intimacy. That is why I wanted to make time to talk about things that turn us both on.” If you are uncomfortable with this idea, start by telling your partner what feels good during sex. Simply saying “that feels good” relays positive feedback to your partner that encourages him/her to continue with that particular action. If you and your partner are very comfortable with your sexuality, you can even try self-stimulating together. Obviously, you know your body better than anyone else, and so it is extremely helpful for a partners to watch the other “turn themselves on”. If you find these ideas unhelpful, you may want to consider a consultation with a sex-therapist. Communication is key to maintaining a healthy sexual relationship. Couples must be willing and able to talk freely with each other, not only to build a strong foundation of trust, but also a strong sense of intimacy and closeness beyond the bedroom.
- Is it okay for me to tell my partner what I want sexually? I don’t want to hurt his feelings or make him feel inadequate.
Absolutely! As discussed previously, communication is key to a healthy sexual relationship. It is perfectly okay and expected for you to openly communicate to your partner what you need and desire in the bedroom. We discussed in our seminar the simplicity of the male sexual response. It is simply on or off. They cannot read our minds and for most men, they find it difficult to “read” our bodies. Oftentimes, men feel inadequate if they think you are not satisfied. Your partner depends on you to be open and direct about what makes you feel good. He will appreciate it. Together, the two of you can develop a very healthy and satisfying sexual relationship!
- My husband doesn’t feel that our sex life is as exciting as it used to be. I never realized this since we have sex at least three times per week. What would you recommend?
First of all, good for the two of you that you make time for sex during the week! It seems as though the two of you may need to communicate more regarding your uncertainty of what is missing and what he feels is missing. Find out what he feels is lacking and take it from there. He may want to experience more “sparks and spice”. If that is the case and you are open to experimentation, go for it and enjoy the benefits. Try changing up your routine by having sex at different times and at different places than what you normally would. Utilize fantasy and role play and consider adding in sexual toys and games. Check our website for references and ideas.
- Being 45 years old and a working mother of two, how do I maintain a steady state of arousal for a husband who expects sex 5 times per week?
You, like many working moms, have so much going on that sex is often the last thing on your priority list. No-one is ever expected to feel constantly aroused and willing to jump into bed at any given moment. With any woman, especially working women with families, it is important to communicate with your partner and agree on a reasonable “plan for sex”. That way you can avoid arguments that often occur from unspoken expectations. If you have difficulty agreeing on a plan, try designating days of the week where each spouse gets to pick the amount of sexual activity. For instance, you would get to pick the level of intimacy on Monday, Wednesday and Friday, and he gets to pick on Tuesday, Thursday and the weekend. This can range from simply a “welcome home kiss” to holding hands while watching a movie to sexual intercourse. If you find it hard to create an agreement, you may benefit from talking to a neutral party together, such as a sex therapist.
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- Can thyroid medications cause sexual problems?
Thyroid disorders are a common cause of desire, arousal and orgasm issues. The correcting of a thyroid disturbance by use of proper medications often resolves these issues. You would have to speak to your prescribing clinician, depending on what specific medication(s) you are on, to figure out if there is a risk of sexual side effects from it/them. If there are no known sexual side effects, you may benefit from seeing a sexual health clinician to rule out other causes of your problems through a detailed health history and physical exam.
- I had back surgery 3 years ago and am doing well overall. However, since then, I find it very difficult to enjoy sex...any reason why?
The nerves that supply the pelvis come from the back. It is certainly possible that the innervation to the pelvis was disrupted from your injury/surgery causing lack of sensitivity. Also, any type of trauma to the back and pelvis can disrupt the muscles, tendons, ligaments, and bones that lead to the pelvis. This can have a huge impact on sex. Unfortunately, without talking to you about specifics regarding your surgery and examining you, I cannot tell for sure what is going on. It could even be something completely unrelated to your surgery...just a coincidence that you noticed it at the same time.
- I recently underwent gastric bypass surgery. What should I expect in the way of sexual or hormonal changes? Should I look for certain symptoms associated with rapid weight loss?
There will be many changes to your body following this particular surgery. If all goes well, hopefully you will have a surge in your libido and sexual satisfaction. This is in part related to stabilization of hormones, lowering of lipids, increase in energy levels, increase in flexibility and stamina, and hopefully an increase in self-image. I’ve had many women tell me they forget what it is like to be “sexual beings” when they are overweight. But it is important to remember that gastric bypass surgery is a very invasive surgery with a lengthy recovery period and high risk of complications. I advise you to chat with your surgeon before embarking on any new sexual escapades.
- Would a hysterectomy cause spinal misalignment?
Anything is possible. More likely is loss of ability to attain physical arousal such as vaginal lubrication and genital swelling/tingling, and inability to or difficulty in attaining orgasm. This is due to the severing of certain nerves in the pelvis during surgery that lead to the genitals. Unfortunately we do not yet know enough about the nerves in the female pelvis to perform “nerve sparing” hysterectomies like we are beginning to perform on men for prostate surgeries. There are ongoing studies that will hopefully tell us more in the near future and help us to avoid this complication. If you feel that this situation may be the case with you, do not lose hope. There are therapies that can be utilized to hopefully counteract this problem.
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- I experience severe perineal pain during sex, I did not have an episiotomy with child delivery. What could this pain be related to?
There are many possible explanations for your pain. Unfortunately, only a comprehensive health history and physical exam can give you answers. The good thing is that WISH specializes in sexual pain disorders, so even if you have seen multiple clinicians who have given you answers such as “there is nothing wrong with you” or “it’s all in your head” or “just relax and have a glass of wine”, it does not mean you will have to suffer with this for the rest of your life. Many of my pain patients have seen five or more clinicians before they get to me and none have properly diagnosed and/or treated. This is not to the fault of the other clinicians. Female sexual dysfunction is a subspecialty that is not routinely taught in medical and graduate schools. This is also why there are so few clinics around the nation that deal specifically with female sexual dysfunction. I recommend to any woman who experiences pain with and without sex to see a specialist. Pain is never normal and it should never be ignored.
- After having sex 2-3 times, I start to hurt. What’s wrong with me?
First of all, I would not jump to the conclusion that something is wrong with you. I do tell patients that pain during sex is not normal, but there may be a simple explanation here. Multiple acts of long periods of intercourse can lead to vaginal irritation and pain. Unfortunately, this contradicts what we see in movies where couples can have passionate sex over and over without difficulty. If you think this is the case with you, try changing up your routine and adding in non-intercourse activities such as oral sex or manual stimulation. Try experimenting with sexual toys, fantasies, and role-playing so that your sexual routine is not all vaginal penetration. If you notice your pain persists or worsens, I encourage you to make an appointment at WISH.
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- My pain is the result of radiation treatments for rectal cancer. I have severe groin burns and went into immediate menopause. I am presently taking Prempro, using vaginal dilators and trying various position changes, of which are little to no help. Do you have any suggestions?
Hormone therapy and vaginal dilators are a typical first-line treatment plan for this type of situation. The good thing is that there are many more alternatives to consider. The first thing that I would concentrate on is addressing your pain. Hormones and dilators are not necessarily going to alleviate your pain from the groin burns. If you were a patient of mine, I would take a health history and complete a full physical exam to determine an appropriate therapy which may include traditional Western therapies and/or alternative therapies. I would then collaborate with the clinicians(s) currently treating you to make sure there are no contraindications to our treatment plan. I would also (most likely) recommend that you see a physical therapist to work on the muscles, bones, tendons and ligaments that are often affected from this type of situation.
- I am a breast cancer survivor. Though my treatments forced me into menopause, I have since recovered completely and find my sex drive insatiable and my periods are heavy and irregular. My doctors refuse to place me on hormones to “balance” things out. What would you recommend?
Once again (I hate to sound like a broken record) but it is very important to know your entire health history and complete a full physical exam before giving recommendations. At WISH, we do not use the same protocol for every patient even if situations are similar. Every patient is unique and thus, treatment plans should follow suit. With breast cancer patients, I sometimes do use hormones, although I am much more careful than with the average patient. There are also alternative ways to manage hormonal imbalances. Acupuncture is one of my favorite alternative therapies. It is a very effective way to safely stabilize hormones and regulate menstrual cycles. It’s also very relaxing.
- Can you tell me more about HPV (human papilloma virus)? How long after exposure can one expect to exhibit symptoms? Can it really be years?
Many sexually active women are infected with HPV, yet they do not even know. HPV is the virus that not only causes genital warts, but is also linked to cervical cancer. There are many different strains of HPV. The strains that cause the genital warts you probably remember from sex education in grade school is ironically very benign and is not linked to cancer. The only problem with visible genital warts is they are ugly. The only reason for removal of warts is for cosmetic purposes. Those strains linked to cancer are often detected on routine Pap smears. Any “abnormal” Pap smear is assumed to be due to HPV infection. HPV lays dormant in a woman’s system until something causes it to present itself such as stress, other infections, pregnancy, etc. Although there is no cure for HPV (it always remains in your system), routine Pap smears usually detect abnormal cell growth before serious consequences occur. There is currently a vaccine being developed that should be available in the next few years. Unfortunately, it is only for use among young boys and girls before they become sexually active, so it is of no use to adults.
- There is a blood test that detects HPV, CA-125. Do you know what it is and the criteria involved?
Actually HPV, or human papilloma virus (see previous question), is detected via a Pap smear or less commonly through a blood test which checks for antibodies to HPV. CA-125 is a blood test that checks for possible cancer activity in the body, specific to ovarian and breast cancer.
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