A Critical Introduction to Human Sexuality
A Critical Introduction to Human Sexuality

A Critical Introduction to Human Sexuality

Lead Author(s): Nicole McNichols, Matt Numer

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A modern, comprehensive and research-based exploration of human sexuality that incorporates real life perspectives on contemporary issues.

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Key features in this textbook

Human Sexualiuty includes Spotlight Stories: Audio interviews that relate text content to the real world, including an interview with Chris Charbonneau, CEO of Planned Parenthood of the Great Northwest and the Hawaiian Islands.
25-40 built-in assessment questions embedded in each chapter, as well as comprehensive test banks for students to test their knowledge.
Full set of slide decks aligned to each chapter of the book; each deck comes with interactive questions, videos and eye-catching visuals.

Comparison of Human Sexuality Textbooks

Consider adding Top Hat’s A Critical Introduction to Human Sexuality textbook to your upcoming course. We’ve put together a textbook comparison to make it easy for you in your upcoming evaluation.

Top Hat

Nicole McNichols, Matthew Numer, “A Critical Introduction to Human Sexuality”, Only One Edition needed

Oxford Press

Baldwin, Janice & John Baldwin & Simon LeVay, Discovering Human Sexuality (3rd ed.)

McGraw-Hill

Hyde, Janet and John DeLamater, Understanding Human Sexuality (13th ed.)

Pearson

Hock, Roger R., Human Sexuality (4th ed.)

Pricing

Average price of textbook across most common format

Up to 40-60% more affordable

Lifetime access on any device

$67.95

E-book

$169.95

Hardcover print text only

$90

E-book

$180

Hardcover print text only

$199.95

Hardcover print text only

Always up-to-date content, constantly revised by community of professors

Content meets standard for Human Sexuality. Constantly revised and updated by a community of professors with the latest content

In-Book Interactivity

Includes embedded multi-media files and integrated software to enhance visual presentation of concepts directly in textbook

Only available with supplementary resources at additional cost

Only available with supplementary resources at additional cost

Only available with supplementary resources at additional cost

Customizable

Ability to revise, adjust and adapt content to meet needs of course and instructor

All-in-one Platform

Access to additional questions, test banks, and slides available within one platform

Pricing

Average price of textbook across most common format

Top Hat

Nicole McNichols, Matthew Numer, “A Critical Introduction to Human Sexuality”, Only One Edition needed

Up to 40-60% more affordable

Lifetime access on any device

Oxford Press

Baldwin, Janice & John Baldwin & Simon LeVay, Discovering Human Sexuality (3rd ed.)

$67.95

E-book

$169.95

Hardcover print text only

McGraw-Hill

Hyde, Janet and John DeLamater, Understanding Human Sexuality (13th ed.)

$90

E-book

$180

Hardcover print text only

Pearson

Hock, Roger R., Human Sexuality (4th ed.)

$199.95

Hardcover print text only

Always up-to-date content, constantly revised by community of professors

Constantly revised and updated by a community of professors with the latest content

Top Hat

Nicole McNichols, Matthew Numer, “A Critical Introduction to Human Sexuality”, Only One Edition needed

Oxford Press

Baldwin, Janice & John Baldwin & Simon LeVay, Discovering Human Sexuality (3rd ed.)

McGraw-Hill

Hyde, Janet and John DeLamater, Understanding Human Sexuality (13th ed.)

Pearson

Hock, Roger R., Human Sexuality (4th ed.)

In-book Interactivity

Includes embedded multi-media files and integrated software to enhance visual presentation of concepts directly in textbook

Top Hat

John Redden & Joe Crivello, Human Physiology, Only One Edition needed

Oxford Press

Baldwin, Janice & John Baldwin & Simon LeVay, Discovering Human Sexuality (3rd ed.)

McGraw-Hill

Hyde, Janet and John DeLamater, Understanding Human Sexuality (13th ed.)

Pearson

Stuart Fox, Human Physiology (14th ed.)

Customizable

Ability to revise, adjust and adapt content to meet needs of course and instructor

Top Hat

John Redden & Joe Crivello, Human Physiology, Only One Edition needed

Oxford Press

Baldwin, Janice & John Baldwin & Simon LeVay, Discovering Human Sexuality (3rd ed.)

McGraw-Hill

Hyde, Janet and John DeLamater, Understanding Human Sexuality (13th ed.)

Pearson

Hock, Roger R., Human Sexuality (4th ed.)

All-in-one Platform

Access to additional questions, test banks, and slides available within one platform

Top Hat

John Redden & Joe Crivello, Human Physiology, Only One Edition needed

Oxford Press

Baldwin, Janice & John Baldwin & Simon LeVay, Discovering Human Sexuality (3rd ed.)

McGraw-Hill

Hyde, Janet and John DeLamater, Understanding Human Sexuality (13th ed.)

Pearson

Hock, Roger R., Human Sexuality (4th ed.)

About this textbook

Lead Author

Nicole McNichols, Ph.DUniversity of Washington

Nicole McNichols is a lecturer in the Department of Psychology at the University of Washington in Seattle, where she also received her PhD in Social Psychology. Over the past five years, Nicole has built her class, The Diversity of Human Sexuality, into the University of Washington’s largest and most popular undergraduate course with over two thousand enrolled students each year. Nicole is frequently a guest lecturer and speaker regarding topics in human sexuality. She was at the forefront of the University of Washington’s push to adopt and develop active learning techniques and technologies to bring scientific subject matter to life in the classroom. Nicole is an active member of a variety of societies for teaching human sexuality and was recently the keynote speaker at the University of Washington’s Psychology graduation. Nicole received her BA from Cornell University and her MA from NYU.

Lead Author

Matthew Numer, Ph.DDalhousie University

Matthew Numer is an Assistant Professor in the School of Health and Human Performance at Dalhousie University and cross-appointed to the Gender and Women’s Studies Program. He has been funded by the Canadian Institutes of Health Research for his work in the areas of gender, sex and sexuality. His research interests include substance use, gay, bisexual and other men who have sex with men’s health, sexual health, online technologies, LGBTQ2S health, masculinities, Indigenous boys’ and men’s health, and post-secondary pedagogical practices. He has received numerous awards for his interactive teaching methods and is widely known as an innovator in the classroom. He is the former Chair of the Nova Scotia Rainbow Action Project, was a member of the board of directors for the Halifax Sexual Health Centre for eight years, and currently serves on the AIDS Coalition of Nova Scotia: Gay Men’s Health Advisory Committee.

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Chapter 11: Fertility

11.1 Learning Objectives

After reading this chapter, you should be able to:

  • Identify the major reproductive hormones present in both males and females. 
  • Describe the male hormone system.
  • Describe the female hormone system, including the menstrual cycle.
  • Explain the ways in which female fertility can be determined.
  • Discuss the psychology of menstruation.
  • Understand the changes in fertility that naturally result in old age. 

11.2 Introducing the Major Reproductive Hormones

The female and male reproductive system involve a fascinating orchestration of events. Reproductive hormones often assume a variety of different roles as they ebb and flow according to very specific cycles and negative feedback loops. The function of these cycles and loops is to make pregnancy possible while keeping the reproductive system in a balanced, harmonious state. 

11.2.1 The Main Reproductive Hormones 

The major reproductive hormones present in both males and females include three significant types: releasing factor, gonadotropins, and sex steroids. 

  • Releasing Factor: The major releasing factor hormone is gonadotropin-releasing hormone (GnRH). It is "released" from the hypothalamus (the blue area in the diagram below) in the brain in order to stimulate the anterior pituitary to release gonadotropins.
  • Gonadotropins: The two major gonadotropins are follicle stimulating hormone (FSH) and luteinizing hormone (LH). These are secreted by the anterior pituitary (the green area) and work to stimulate the gonads, (i.e., ovaries and testes).
  • Sex steroids: The major sex steroids include androgens (e.g., testosterone), estrogens (e.g., estradiol), and progestins (e.g., progesterone). These hormones are released by the ovaries, the testes and the adrenal glands (the red area) and work to stimulate many bodily tissues including the uterus, the penis and hair follicles. 
Figure 11.1. The hypothalamus (blue) secretes GnRH to stimulate the anterior pituitary (green) to secrete FSH and LH to stimulate the adrenal glands (red) and gonads (not shown) to produce androgens, estrogens, and progesterones. The main source of androgens (testosterone) in males comes from the testes. Females produce much smaller amounts of androgens from the adrenal glands. [1]
Question 11.01

Match the hormone with its correct reproductive function.

Premise
Response
1

GnRH

A

Released by the pituitary and stimulates testosterone production in interstitial cells of testes and estrogen production in ovaries.

2

LH

B

Released by the hypothalamus and stimulates the pituitary.

3

FSH

C

Released by the pituitary and stimulates sperm production in seminiferous tubule of testes and ripening of follicles in ovaries.

11.3 The Male Hormone System

Compared to the female hormone system, the male system is remarkably straightforward. Hormones are released non-cyclically, meaning that they are produced at the same level every day. As such, the male hormone system progresses according to the following sequence: 

  • GnRH is released by the hypothalamus and stimulates the release of LH and FSH from the anterior pituitary.
  • LH promotes hormone production (primarily testosterone) in the interstitial cells of the testes. (Reminder: the interstitial cells are the cells that are in between the seminiferous tubules in the testes, which is where sperm production takes place.) 
  • At the same time, FSH stimulates sperm production in the seminiferous tubules.

In the male, the function of LH is to stimulate testosterone production. Testosterone functions to maintain accessory glands (such as the prostate), to give rise to and maintain secondary sex characteristics, to increase libido and to stimulate bone growth. The function of FSH is to stimulate the seminiferous tubules to produce sperm. When a male's sperm count reaches a certain threshold, the hormone inhibin is released by the cells in the seminiferous tubules. LH-stimulated testosterone production and FSH-stimulated sperm production occur simultaneously, meaning that both rise and fall in synchrony. To regulate this system, a negative feedback loop exists whereby rising testosterone and inhibin levels serve as a gauge for when sperm production should be turned on or off. When testosterone and inhibin levels go above a certain set point, the hypothalamus and pituitary respond by inhibiting GnRH, LH, and FSH production, which in turn stops the production of testosterone and sperm. When testosterone levels dip too low, the hypothalamus and pituitary kick back into action, which stimulates GnRH, LH, and FSH to trigger testosterone and sperm production once again.

Figure 11.2. The male reproductive hormone system relies on a negative feedback loop. When inhibin and testosterone levels exceed a certain set point, the pituitary slows production of LH and FSH.​ When testosterone levels exceed a certain set point, the hypothalamus also slows production of GnRH.​

It takes approximately 70 days to produce a fully mature sperm. Nevertheless, a male's sperm count is replenished approximately every 24 hours. For this reason, ejaculations that are repeated more frequently than once every 24 hours can lead to lower sperm count, since the body has not had enough time to catch up in producing sperm. Frequently, couples trying to conceive think that they need to have sex as often as possible, but in truth more is not necessarily better.

Once inside a fertile female body, a sperm typically has a lifespan of between 24 and 48 hours. However, there can be quite a range; the longest observed sperm viability is five days. Sperm require an alkaline (versus acidic) vaginal environment to survive. Luckily, the female vagina becomes more alkaline around the time of ovulation, thereby facilitating fertilization. Nevertheless, the vagina can be a fairly hostile environment for sperm given the many antibodies that live in the vagina and may attack sperm. Fortunately, semen does provide sperm some protection from these antibodies.

As shown in the animated video that begins this chapter, only a small number of sperm will make it through the cervix and into the oviducts, where they can fertilize an ovum. To help sperm get to where they need to be, the cervix secretes muscin around the time of ovulation. Muscin is at the ideal PH for sperm to thrive. During times of peak fertility, muscin helps sperm survive as they pass through the cervical opening and into the uterus, where sperm has a chance of reaching the oviducts and encountering an ovum.      

Although there is no lunar cycle of hormones in the male, testosterone levels fluctuate slightly according to both the time of day as well as the season. Specifically, testosterone levels tend to peak in the morning and decline in the late afternoon, and they also tend to peak in the late fall/early winter and hit a low point in late spring/early summer. These changes are relatively slight and usually do not have a major impact.

The following video describes recent research indicating that male fertility (as measured by average sperm counts among men) is on the decline. Although this is hardly a threat to the human race, it does raise concerns about the general state of male reproductive health in the world today. 

Question 11.02

The male reproductive system relies on a negative feedback loop, meaning that as _______ rises above a certain level, the hypothalamus and pituitary are triggered to stop producing GnRH, FSH, and LH.


Question 11.03

Which of the following statements about sperm is correct?

A

They are susceptible to attack by antibodies once in the female vagina.

B

They live in the female body for at most 12-24 hours.

C

They thrive in the acidic muscin in the female.

D

They gain the capacity to fertilize the ovum from enzymes in the cervix.

11.4 The Female Hormone System 

As opposed to the adult male hormone system, which simply governs the production of sperm, the adult female hormone system has a much more complicated task. It governs the menstrual cycle, which prepares the body approximately every month for a potential pregnancy. 

11.4.1 Overview of the Menstrual Cycle

What constitutes "typical" when it comes to the length of the menstrual cycle? A cycle is considered to be "typical" if all of the hormonal events occur in the proper sequence. Many people erroneously believe that the menstrual cycle is always 28 days, but in truth, this merely represents a statistical average. Many women experience a 28-day cycle only if they are taking hormones (i.e., the birth control pill) to regulate the cycle.  

The length of cycles can vary even for the same female. A variation of as much as five days in each cycle is still considered regular. On average, women's cycles become longer and more regular as they age until they approach menopause, at which point deregulation occurs. Furthermore, monthly menstruation is not necessary for health reasons and total suppression of the menstrual cycle by some types of hormonal contraceptives is common and poses no health risk. From an evolutionary standpoint, monthly menstruation over a long period may not even be normal, given the many common events (e.g., pregnancy, lactation, menopause, late puberty, stress, seasonal fluctuations) that regularly suppress it. Up until only a few hundred years ago, it was common for women to have eight to 10 pregnancies over their lifetimes, each of which caused yet another long cessation of their monthly cycle.

Question 11.04

Which of the following is true about the menstrual cycle?

A

They are abnormal if they last longer than 30 days.

B

They are normal if the hormonal events occur in the proper sequence.

C

They become increasingly more variable as women age from 20-40.

D

They lengthen as a woman approaches menopause.

11.4.2 The Phases of the Menstrual Cycle

There are five phases of the menstrual cycle which occur in the same sequence each cycle. 

The first phase, the follicular phase, technically begins at day four in the menstrual cycle. The reason it does not begin on day one is that the medical community designated day one as the day that menstruation ("menses") begins since it is the most easily observed and measured event in the cycle. The cycle truly "begins", however, with the follicular phase. 

The follicular phase extends from day four to day twelve on average, but its length may vary substantially for different women and even cycle to cycle for the same woman. The large differences in the length of this phase are the reason there is so much variation in the length of menstrual cycles overall. 

During the follicular phase, GnRH is steadily released from the hypothalamus and stimulates the pituitary to release LH and GnRH. LH causes the ovaries to produce estrogen. Rising estrogen levels in the female body cause the uterine lining (the endometrium) to thicken in preparation for a potential pregnancy. At the same time, the pituitary also releases FSH, which causes the growth of a small collection of follicles in the ovaries, resulting in the maturation of the ova inside the follicles.

Toward the end of the follicular phase and immediately prior to ovulation, increasing estrogen levels reach a set point. The high estrogen levels cause the vagina's "hostile" (i.e., acidic, dry, tacky) cervical mucus to give way to increasingly "friendly," (i.e., alkaline, clear, slippery) mucus.    

Figure 11.3. Notice how during the follicular stage estrogen levels steadily rise while progesterone remains low. Also notice the surge in LH that occurs immediately prior to ovulation. The very top image shows how the uterine lining continues to thicken until menstruation.​​

The second stage of the menstrual cycle is ovulation. Ovulation always occurs about two weeks prior to the start of a women's menstrual period. In a 28 day cycle, this means that ovulation occurs between day 13 and 15.  

As previously described, at this point in the cycle estrogen has risen to its set point. During ovulation, estrogen levels will exceed this set point, causing the hypothalamus to begin pulsing the release of GnRH. As a consequence of GnRH pulsing, the pituitary has a surge in the release of FSH and especially LH, causing one (usually) follicle to fully ripen and release an ovum to the fimbria and into the oviducts. This event marks the period of maximum fertility during the cycle.

A number of physical changes in the body also accompany ovulation. Cervical mucus changes to be hospitable to sperm by becoming alkaline, copious, watery, elastic, slippery and akin to raw egg whites. At the same time, the cervix softens and rises within the vaginal canal, and the cervical os opens to allow for the potential transport of sperm. Finally, the corpus luteum forms from the evacuated follicle in the ovary.  

The luteal phase follows immediately after ovulation and always lasts for 14 days (varying by only a day or two), making it the most regular and predictable part of the menstrual cycle. During the luteal phase, LH stimulates the corpus luteum to secrete estrogen and progesterone. As a result of progesterone, cervical mucus turns "hostile," meaning that it becomes less stretchy and more dry and acidic. Progesterone also causes the remaining follicles to shut down so that further ovulation is actively inhibited. Finally, progesterone prohibits prostaglandins, which are also secreted during the luteal phase. By prohibiting prostaglandins, the myometrium (the middle, muscular layer of the uterus) is prevented from contracting and shedding its inner layer. 

Should fertilization occur, implantation of the fertilized ovum will occur a few days after ovulation, during the luteal phase.

The premenstrual phase is also referred to as the "late luteal phase." During this phase, the corpus luteum degenerates, causing progesterone and estrogen levels to decline. Without progesterone to inhibit them, prostaglandins begin causing the myometrium to contact, causing what is commonly experienced as menstrual cramping. This can also sometimes cause bloating and other physical symptoms in some women. 

The destructive phase of the cycle is when menses (or "menstruation") occurs. During this phase, progesterone, estrogen, FSH and LH are all low. Withdrawal of estrogen causes the endometrial lining, which had been growing thicker and richer throughout the month, to break down and exit the body through the vagina. In some women, the cramping which begins in the premenstrual phase grows more intense as prostaglandins become completely exposed due to low progesterone levels. Toward the end of the destructive phase, GnRH begins to rise steadily, causing FSH to also rise, thus preparing for the start of a new cycle.             

Figure 11.4. Diagram of hormonal and uterine changes that occur during the menstrual cycle. Notice how basal body temperature rises immediately following ovulation.​

The phases of the menstrual cycle and the corresponding changes discussed above are explained in this video below.


Question 11.05

The follicular phase of the menstrual cycle:

A

Has the most consistent length of all the phases.

B

Is characterized by a decrease in estrogen.

C

Is characterized by the thinning of the uterine lining.

D

Is the first phase of the menstrual cycle.


Question 11.06

The destructive phase (menses) includes all of the following except:

A

The breakdown of the endometrium.

B

Contractions of the uterine myometrium.

C

Low levels of progesterone and estrogen.

D

Low levels of prostaglandins.

11.5 Tracking Changes in the Body to Determine Fertility

There are many reasons why people are interested in tracking their own or their partner's times of peak fertility. Perhaps the couple wants to get pregnant and would like to make sure they are timing intercourse to maximize the chance of a pregnancy occurring. Alternatively, a person or couple may be trying to avoid pregnancy and would like to identify the times when they should avoid intercourse or increase protection. Regardless of the reason, learning to interpret the physical signs of fertility can be a psychologically empowering and useful tool.

Figure 11.5. Image of a sperm and egg fusing. [5]

11.5.1 The Calendar Method

This method uses the calendar of a woman's monthly cycle to track the days during which she is most likely to be ovulating. It is probably the most common method since it is the simplest. It merely involves counting 14 days (the average length of the follicular phase) from the start of the cycle and assuming that ovulation occurs on that day. The problem with this method is that, as discussed above, the length of the follicular phase in a given cycle can vary by several days. In truth, 28 days represents a statistically average cycle and women rarely ovulate exactly on day 14. Consequently, the calendar method is an extremely unreliable way to predict fertility. 

11.5.2 Tracking Cervical Mucus Changes

As estrogen rises during the follicular phase, mucus transforms from being "hostile" (dry, tacky) to "friendly" (wet, slippery) to fertile (very stretchy and clear, like raw egg white), and finally back to "hostile" again after ovulation occurs. The appearance of fertile cervical mucus usually precedes the LH surge by one day. The LH surge in turn, drives ovulation in the next twelve to 24 hours. Learning to evaluate one's own (or one's partner's) cervical mucus is therefore a very effective way to estimate the timing of ovulation.     

11.5.3 Using Cervical Changes 

The cervix also undergoes predictable changes that coincide with peak fertility windows. The cervical os is hard and closed (similar in touch to the tip of one's nose) when fertility is low, and soft and open (similar in feel to partly opened lips) when fertility is high. Since the cervix opens and softens during ovulation, checking it can be an effective way to determine fertility. This method is extremely effective, especially if used in conjunction with tracking cervical mucus.

11.5.4 Using Basal Body Temperature

Basal body temperature is temperature when you are fully at rest. It can be measured with a special thermometer and rises and falls in a predictable pattern that aligns with ovulation. Specifically, prior to ovulation, temperature is relatively low (below 98.0F). Rising progesterone levels following ovulation cause a simultaneous rise in body temperature, elevating it by about half a degree. At the end of the cycle, when progesterone falls, body temperature returns to its original cooler state. 

A rise in basal body temperature therefore indicates that ovulation has passed. Since ovulation only causes basal body temperature to rise by half a degree, it is hard to detect. Temperature must be taken first thing in the morning before getting out of bed. Even a quick trip to the bathroom can be enough activity to boost temperature above its basal state, causing one to erroneously conclude that ovulation has passed. Although this method is not safe to rely on by itself, it can nonetheless be used to confirm or question other signs of fertility.      

Figure 11.6. Notice how basal body temperature spikes immediately following ovulation.​


Question 11.07

A female is most likely fertile if:

A

It is 20-22 days past her menses.

B

Her cervical os is soft and open.

C

Her basal body temperature has risen above 98.0F.

D

Her cervical mucus has changed to become more tacky and sticky.

11.5.5 Ovulation Predictor Kits

Ovulation predictor kits (OPKs) are similar in look to at home pregnancy tests and can be purchased at your average drugstore. An OPK can indicate when a female is most fertile by detecting the surge in luteinizing hormone (LH), which occurs roughly 36 hours before ovulation. The accuracy of OPKs relies on the fact that by timing coitus shortly after this LH surge, a couple can increase their odds of uniting a sperm and egg. 

OPKs are precise, easy and convenient, but they have a number of drawbacks. Since they are only testing for a surge in LH, a negative test can not tell you if ovulation has yet occurred, or if not, how far away it is. This can lead to the need for frequent re-tests which can grow expensive, as well as psychologically draining. 

11.5.6 Myth: Sex During Menses Cannot Lead to Pregnancy

Aside from the physical signs of fertility discussed above, there are two factors that need to be kept in mind in estimating the possibility that intercourse will lead to a pregnancy. First, although sperm typically survive from 24 to 48 hours inside the vagina, it is possible for them to survive up to five days, depending on the state of cervical mucus. Second, menstrual cycles vary, and in a shorter cycle, ovulation will occur closer to menstruation than in a longer cycle.

All of this leads to the main point of this subsection, which is to discredit the notion that sex during menses presents no risk of pregnancy. During the tail end of the destructive phase ("menses"), cervical mucus starts becoming friendly once again. Consequently, should sperm be deposited inside the vagina during this time (shown in "Cycle B" below), and should that sperm live for up to five days, and should the woman have a shorter cycle, she could easily ovulate while these sperm are still viable, thus leading to pregnancy. Or, imagine a female with a 28-day cycle but with a menses that lasts eight days, instead of the typical four to five (shown in "Cycle C" below). Should sperm be deposited the last day of her menses, it could easily remain viable until this female ovulates on day 14. Interpreting the presence of menstrual blood as a sign that one is "in the clear" so to speak is a risky strategy, to say the least.

Figure 11.7.​ Female A shows a situation where coitus occurs the last day of the menstrual cycle in a 28-day cycle. In this case, pregnancy does not occur. Female B and C both show how coitus during menstruation could easily lead to pregnancy, however.​


​Christy Jones is the founder of Extend Fertility, the first service in the U.S. dedicated exclusively to women choosing to proactively freeze their eggs. Listen to Christy describe the challenges that many women and couples face when trying to get pregnant, and how technologies such as egg freezing offer one option for women who wish to delay pregnancy yet preserve their fertility.

Question 11.08

Question 11.08

What are the common types of emotional and psychological responses that many women have in response to finding out that they have fertility issues?

Question 11.09

Question 11.09

Do younger women ever experience anxiety about becoming infertile later in life?

Question 11.10

Question 11.10

Historically, what types of treatments have been available for women who struggle with infertility?

Question 11.11

Question 11.11

How does egg freezing differ from these procedures?

11.6 The Psychology of Menstruation

How does menstruation impact sexual behavior? How does it impact mood? What is PMS really like? The video below provides an overview of how changes in hormones related to the menstrual cycle translate into changes in mood and behavior.

11.6.1 Sexual Behavior During Menses  

In Western culture, there is a bit of a social "menstrual taboo" that affects the timing of sexual activity. The "taboo" rests on false beliefs about the "cleanliness" of menstrual blood and the idea that menstruation is embarrassing and even shameful.  

Menstrual blood is composed of endometrial cells, interstitial fluid, bloodm and mucus. It is completely sterile and not at all a health hazard by itself. It does not contain any bacteria (until it is exposed to air). The one exception regarding the safety of menstrual blood concerns HIV and Hepatitis B/C. Females who are infected with these diseases will contain the virus in their menstrual blood.  

The risks for a female who engages in sexual activity during menstruation are slightly greater than at other times her cycle. This is mainly due to the open position of the cervix during menses, which increases the risk of introducing infectious microbes (e.g., STIs) into the upper genital tract, causing pelvic inflammatory disease. As the vagina turns more alkaline during the latter part of menstruation, this open position also allows the growth of harmful microbes. On the positive side, orgasm during menstruation can be an effective way to reduce uterine cramping.  

Psychologically, females, especially in Western culture, often suffer from concerns regarding their relative attractiveness during menstruation. Westerners tend to view menstrual blood as disgusting, shameful, dangerous and unclean, and this leads to a negative, non-erotic sexual image of a menstruating female. Menstruation and the period leading up to it can cause water retention, which often leads to swelling of the face, extremities, and waistline, leading to the experience of "feeling fat." In addition, increased oil production during this time can also lead to pimples, leading the female to feel less than desirable.

Males tend to experience their own issues while their female partners are menstruating. They might have concerns about the moral acceptability of sexual activity during menstruation. They may feel turned off, scared, embarrassed or they may just be ignorant. Some males feel uncertain about how best to approach their female partners during this time, whereas others experience increased sexual interest that comes from a reduction in the fear of pregnancy.  

To help calm some of these fears, there are a number of strategies couples can use to manage menstrual flow during sex. Some just choose to avoid certain types of sexual activities during menstruation, such as oral sex or manual stimulation. Some couples choose to keep a towel or washcloth handy for cleanup before or after sex. Menstrual cervical cups are also ideal for collecting menstrual blood during sex. The cup needs to be removed shortly after sex to eliminate the risk of toxic shock. Also, some couples enjoy the extra lubrication that menstruation provides for coitus, and find that it makes orgasm for both partners more achievable.  

Question 11.12

Which of the following is true regarding sex during menstruation?

A

It presents a minor health risk as menses does contain bacteria.

B

It is reported by most to be generally unenjoyable for both partners.

C

It can lead to a decrease in uterine cramping if the female experiences orgasm.

D

It carries a lower risk of introducing infectious microbes into the genital track since the cervical os is closed.

11.6.2. Premenstrual Syndrome (PMS)  

Premenstrual syndrome (PMS) refers to the physical and emotional changes that occur in the premenstrual (late luteal) phase of a female's menstrual cycle. It is common for women to experience a moderate degree of physical discomfort or negative mood change in the couple of weeks prior to when menstruation begins. Symptoms of PMS include tension/anxiety, sadness, mood swings, aches, altered appetite or food cravings and cramps. Physical symptoms of PMS include bloating, fatigue, irritability, tender breasts, acne, and mood changes. The average duration of these symptoms is six days, with patterns changing for most women over time. These effects are mainly caused by depressed levels of progesterone and estrogen and increased levels of prostaglandins and androgens, which impacts the female body in the following ways.

Decreased estrogen causes:

  • electrolyte imbalance, which causes water retention, bloating, vitamin deficiency (calcium, magnesium, B complex), and irritability 
  • change in carbohydrate metabolism, which causes cravings for sweets, weight gain, fatigue, depression.
  • change in vaginal PH, which makes the vagina more susceptible to infections 
  • breast tenderness

Decreased progesterone (combined with increasing prostaglandins) causes:

  • uterine cramping and lower back pain, both of which can usually be treated with ibuprofen

Androgen, which is "unmasked" by low levels of estrogen and progesterone, causes:

  • oily skin, pimples, acne
  • hostility, irritability

How prevalent is PMS? The vast majority of women experience at least one or two symptoms before each period. Research shows that up to 80% of females experience physical changes that are certainly bothersome but cause no significant impairment (Biggs & Demuth, 2011). About 20% to 30% of college-aged women report more moderate discomfort. Most women in this category report being able to effectively manage PMS by getting extra rest and using non-prescription medication (i.e., ibuprofen, etc.) Only 3% to 8% of women report symptoms that are so severe as to qualify for the diagnosis of premenstrual dysphoric disorder (PMDD). In these cases, medical intervention, usually in the form of a common antidepressant referred to as SSRIs, is usually helpful. Historically, the popular media has portrayed PMS as far more extreme than it is in most women. This unfortunately encouraged sexist beliefs that dismissed any woman's bad mood or unfriendly behavior with the comment "oh, she's PMS-ing." Fortunately, there is less negativity associated with menses today than in the past, with more girls seeing it as a step to adulthood. 

 Aside from hormonal changes, the negative emotional effects of PMS are often intensified by cultural influences. The fact that so much emphasis is placed on female attractiveness and that attractiveness serves as the basis of many women's self-esteem can make the physical effects of PMS (bloating, weight gain, blemishes) especially trying. Western society's excessive preoccupation with "feminine hygiene" can also amplify a woman's sense of feeling "unclean" and "unsexy" during menstruation. Adding to this, Western society's portrayal of menstruating females as "diseased," sexually unappealing and "crazy" only serves to exaggerate the negative psychological effects of PMS.

Question 11.13

Which of the following hormones is matched with the likely physiological cause of PMS symptoms?

A

Decreased progesterone -change in vaginal PH - risk for vaginal infections.

B

Decreased estrogen - carbohydrate metabolism, intensified craving for sweets.

C

Decreased estrogen - uterine cramping due to unmasking of prostaglandins.

D

Increased androgens - breast tenderness.

11.7 Cross Cultural Perspectives on Menstruation

There is a wide range of attitudes toward menstruation that exists among different cultures based primarily on how erotophobic (fearful of sex) versus erotophilic (sex positive) they are. Cultural attitudes can be divided into the following four broad categories:

  • Very Erotophobic: Menstruation is regarded as akin to contamination (the "curse"), and treated with secrecy and shame (e.g., separation from "clean" society, menstruating females treated as if they are diseased and forced to reside in a separate dwelling).
  • Erotophobic: Menstruating women are regarded as sexually and socially unappealing.
  • Erotophilic: First menstruation is regarded as a rite of passage into womanhood, and gives rise to the assumption of new privileges, (e.g., celebration, gift giving).
  • Very Erotophilic: Menstruation is regarded as sacred and healing (e.g., menses used in love potions, cures, religious rites).

Most early Western traditions fell primarily into the first category, reflecting extreme erotophobia. In early Catholicism, for example, menstruating females, including nuns, were excluded from sanctified places as well as communion. Likewise, in the Orthodox Jewish religion menstruating females are considered "unclean" and were traditionally excluded from the religious community as well as the marital bed and were required to undergo a type of ritual cleansing bath ('mikva") before being allowed to re-enter community life and marital relations. In Islamic traditions, menstruating females were also excluded from religious observances and the marital bed.

In many non-Western cultures, extremely erotophobia is frequently reflected in certain cultures as well. Among the Dogon people of Mali, Africa, for example, menstruating females are sequestered for five days each month away from their communities and families in highly visible menstrual huts. Interestingly, researchers believe that these huts may serve to help males control their wives by knowing exactly when they menstruate. In a recent study, one researcher found via genetic testing that in fact, fathers in the Dogon culture were four times less likely to be raising someone else’s son than those who practiced Christianity (Strassmann et al., 2012). Oftentimes these huts are quite dangerous, considering especially that menstruating females are often forced to reside in them alone with little to no contact with other members of their community. In July 2017, for example, a girl in Nepal died after being bitten by a snake while forced to live alone in a menstrual hut. 

Although menstrual huts do not exist in the U.S., less severe erotophobic attitudes concerning menstruation prevail among many people. There remains a level of shame, fear, disgust, and ignorance surrounding menses that causes many females to experience the event as irritating, uncomfortable and embarrassing. Many researchers believe these attitudes have fueled an epidemic of PMS, caused by many females internalizing the negative attitudes and messages they experience concerning menstruation. This is not true among all American women, however. For many, the first menstrual period marks an entry into womanhood and is thus remembered not only clearly but with a sense of pride, empowerment and heightened feelings of femininity. 

How about truly erotophilic cultures that embrace menstruation as a celebrated event? In Japanese culture, many families bestow gifts upon newly menstruating girls that include special nourishing foods and treatments. Japanese families also serve Sekihan, an adzuki-bean and rice dish, the red color of which symbolizes happiness and celebration. In the African Dagara culture and in most of South India, first menstruation is also celebrated with a party marking the female's newfound ability to bear children. The Navajo also have a ceremony called Kinaalda, which is a four-day long ritual that includes running (representing a show of strength) and the baking of a large cornmeal cake to feed the celebrant’s tribe and family. The Nuuchahnulth, a First Nations tribe of Pacific Northwest Canada, celebrate a girl's first menstruation by taking her on a boat out to sea. Her village cheers for her from shore, and watches as she heroically jumps from the boat and swims back to the beach. Menstruation in these cultures connotes feminine strength and endurance, as these celebrations reflect.

Question 11.14

In erotophilic (sex positive) cultures, menstruation is likely to be viewed as:

A

A rite of passage into womanhood.

B

Dangerous, disgusting, polluting.

C

A sign of immaturity.

D

Mysterious and unknown.


In a recent article, the New York Times reported that many countries around the world, including India, Japan, Italy, and South Korea have laws requiring all companies to grant female employees paid time off on days when they are experiencing menstrual pain. Although the original intentions of these laws may have been good, many scholars voice concern that the policies perpetuate the notion that women are weak and unfit for work while they are having their periods. Read the article, and give your opinion on this topic below. 

Question 11.15

What do you think of the idea of a menstrual leave policy? Do you think these laws ultimately help or hinder women?

11.8 Fertility in Aging Adults

Females reach their peak level of fertility in their 20s. In their 30s, fertility begins a slow steady decline. As females approach their early or mid-40s, their menstrual cycles often become less regular, marking a gradual transition to infertility, which ultimately ends in menopause. Menopause is officially "confirmed" when a woman has gone 12 months without a period in the absence of other factors (pregnancy, stress) that could otherwise cause her cycle to stop. Among American, Canadian and European females, the average age at which menopause occurs is 51; however, there is a lot of variation around this number. For South American and Asian females, the average age is lower, in the mid-40s. Although researchers have historically focused on the negative aspects of menopause, some point out that it plays an important role in our evolutionary history. As suggested by the "grandmother hypothesis," the cessation of the menstrual cycle while a female is at full physical capacity allows her to devote precious time and resources (namely food and knowledge) to their adult children, which in turn allows them to be better parents. In post-modern times, females who lived for many years after menopause had more surviving grandchildren than those who did not, giving this theory some credibility (Hawkes & Coxworth, 2013).

What causes a female to enter menopause? Genetics play a factor. Having children extends the age at which menopause occurs. Those who have short cycle lengths, have not used oral contraceptions, or who have had an ovary removed are more likely to experience menopause at a younger age than average. This observation, combined with the fact that FSH and LH increase (rather than decrease) after menopause, suggests that menopause is caused by a depletion of ova (Santoro & Randolph, 2011). Whereas a hysterectomy will put a stop to menstruation, the hormonal events underlying it will continue unless the ovaries themselves are removed. What about lifestyle factors (Morris et al., 2012)? Smoking and not eating meat are correlated with earlier menopause, whereas strenuous exercise, a high body mass, and drinking alcohol are associated with it occurring later.  

The decline in estrogen that occurs with menopause can result in a decline in the vaginal lubrication that normally occurs in response to sexual arousal, making sex potentially painful. Menopause also destabilizes blood vessels, bringing on hot flashes (a sensation of warmth followed by a chill) as well as night sweats, tiredness, headache and heart palpitations (Pachman, 2010). Lower estrogen can also cause loss of bone density, leading to osteoporosis. How are these symptoms treated? This is actually a highly controversial topic that is constantly being refined to reflect new data. Before 2000, menopausal females were often advised to take sex hormones or other drugs to compensate for their lower naturally occurring levels of these hormones. Estrogens were usually given to combat the side effects of menopause, whereas progestins were given to protect against endometrial cancer, which is an unwanted side effect of taking estrogen. In 2002, large scale studies began showing that the long-term use of menopausal hormone therapy leads to cardiovascular disease, breast cancer, and dementia and thus should only be used for short-term relief of menopausal symptoms (Shumaker et al., 2003). Now, however, the tide has changed again, as studies show that these risks are believed to apply primarily to older females, suggesting that menopausal hormone therapy is safe and recommended for females under 60 who continue to suffer from menopause-related symptoms (Rozenberg et al., 2013).

What about males? Although males do not experience a sudden or complete cessation of fertility the way females do, they do experience declining sperm counts, declining ejaculate volume, and an increased likelihood of having erectile disorder. This decline does not start in men until age 40, where then the decline is slow, losing only about 1% a year. In addition, these symptoms often lead to a decline in sexual desire. Collectively, these effects are sometimes referred to as "male menopause," or andropause. To address the decline of sexual function in aging male populations, the pharmaceutical industry has tried to convince many that andropause, as well as the decline in overall health and vitality that occurs in males as they age, can be rectified with supplemental testosterone. The reality, as reflected by research, is that testosterone levels do not affect sexual functioning in aging men until they fall below a certain level that is only encountered by 1 in 1000 males in their 40s, and 1 in 20 males in their 70s (O'Connor et al., 2011; McBride et al., 2016). In addition, the range for what is considered a normal level of testosterone varies between males, which makes it hard to supplement if a baseline was never established. For those who do test low for testosterone, there is conflicting data regarding the long-term benefits and risks of testosterone supplementation. Whereas some studies have shown a decrease in mortality, others have demonstrated an increase in adverse effects including prostate cancer and other forms of cancer (Shores et al., 2012; Basaria et al., 2010). Testosterone supplementation can also worsen benign enlargement of the prostate, which is very common in older males.  

Question 11.16

As suggested by the "________ hypothesis," the cessation of the menstrual cycle while a female is at full physical capacity allows her to devote precious time and resources (namely food and knowledge) to their adult children, which in turn allows them to be better parents.


Question 11.17

According to research on testosterone supplementation,

A

It is effective in males who wish to increase their feelings of vitality.

B

Some studies have shown that it leads to increased mortality.

C

Some studies have shown that it decreases the risk of prostate cancer.

D

It is effective only in males who show below normal levels of testosterone, and even then it still carries risks.

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11.9 References

Biggs, W. S., & Demuth, R. H. (2011). Premenstrual syndrome and premenstrual dysphoric disorder. American Family Physician, 84(8), 918-924.

Chiazze, L., Brayer, F. T., Macisco, J. J., Parker, M. D., & Duffy, B. J. (1968). The Length and Variability of the Human Menstrual Cycle. JAMA: The Journal of the American Medical Association, 203(6), 377-380. doi:10.1001/jama.1968.03140060001001

Lenton, E. A., Landgren, B. M., Sexton, L., & Harper, R. (1984). Normal variation in the length of the follicular phase of the menstrual cycle: effect of chronological age. BJOG: An International Journal of Obstetrics and Gynaecology, 91(7), 681-684. doi:10.1111/j.1471-0528.1984.tb04830.x

Office of Women's Health, USA. Menstrual Cycle. (2017, November 13). Retrieved December 13, 2017, from https://www.womenshealth.gov/menstrual-cycle

Office of Women's Health, USA. Premenstrual syndrome (PMS). (2017, November 13). Retrieved December 13, 2017, from https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome

Sherwood, L. (2013). Human Physiology: From Cells to Systems (8th ed., pp. 735-794). Belmont, CA: Cengage.

Silverthorn, D. U. (2013). Human Physiology: An Integrated Approach (6th ed., pp. 850-890). Glenview, IL: Pearson Education.

Vostral, S. L. (2011). Under wraps: a history of menstrual hygiene technology. Lanham, MD: Lexington Books.


11.10 Answers to Discussion Questions​

Answer to Question 11.08

Women often feel caught off-guard by the experience. Fear, uncertainty, and stress over the financial aspects are common reactions.


Answer to Question 11.09

Yes, particularly if they don’t have a sperm source (either a partner or husband or the desire to have a child on their own). Women often feel like they have a ticking biological clock and that things are out of their control.

Answer to Question 11.10

Couples often go through different work-ups first in an effort to diagnose the problem. Sometimes the issue is with the women’s fertility, but sometimes it is also from the male. There are different types of ovulatory issues that women face, or there may be an issue with the sperm having enough mobility to reach the egg. Typically, treatments are tailored to meet these issues. These may include inter-uterine insemination, (so sperm don’t have to travel as far to reach to the fallopian tubes) or higher-tech options like in vitro fertilization, which involves a process of taking many hormones to grow many eggs at once, retrieving these eggs, fertilizing them with sperm outside the body and then surgically implanting them back in the uterus where they will hopefully develop into a viable pregnancy. This can be an emotionally draining experience and quite often, especially for older women in their 40s, may fail due to the quality of their eggs.

Answer to Question 11.11

Egg freezing is a good option for younger women who are in their early 30s and fear that they may face infertility some day. It preserves the quality of the egg, so that later in life a woman in her 40s, for example, can use an egg from when she was younger, which gives it the best chance of turning into a baby.


11.11 Image Credits

[1] Image courtesy of Anatomography under CC BY-SA 2.1 JP.

[2] Image courtesy of Boghog under CC BY-SA 3.0.

[3] Image courtesy of Doc James under CC BY 3.0.

[4] Image courtesy of Begoon under CC BY-SA 3.0.

[5] Image courtesy of Cropbot in the Public Domain.

[6] Image courtesy of BruceBlaus under CC BY-SA 4.0.

[7] Image courtesy of Nicole McNichols, used with personal permission