Psychosexual problems

Difficulties with sex are extremely common, and almost nobody talks about them. Many women find there is simply nowhere to go — the subject does not come up in a routine appointment, there is rarely a service to be referred to, and the embarrassment on both sides means it goes unmentioned for years. I think that is a real gap, and I am very happy to see women and couples about it.

Why this deserves proper attention

Sex matters. It affects confidence, intimacy, relationships and general wellbeing, and when it becomes painful, frightening or simply absent, the effects reach well beyond the bedroom.

Yet these problems are often dismissed as something to put up with, or attributed vaguely to stress or age. In my experience there is usually something identifiable going on, and something that can be done about it.

Problems women commonly describe

Every story is different, but the difficulties I am asked about most often include:

• Pain during or after intercourse
• Inability to have penetrative sex, or severe tightening of the muscles that prevents it
• Vaginal dryness and discomfort, particularly around and after the menopause
• Loss of desire, or a mismatch in desire within a relationship
• Difficulty reaching orgasm, or a change in sensation
• Bleeding after sex
• Anxiety or fear about sex, sometimes following childbirth, surgery or a difficult past experience
• Changes following cancer treatment, or after gynaecological surgery

The causes are usually mixed

It is rarely purely physical or purely psychological, and it is unhelpful to force it into one box. Hormonal change, skin conditions such as lichen sclerosus, endometriosis, scarring, infection, pelvic floor muscle overactivity and medication side effects can all play a part.

So can anxiety, low mood, exhaustion, relationship difficulties, past trauma, and the entirely understandable fear of pain once sex has hurt before. Often several factors feed each other, which is why looking at the whole picture works better than chasing one cause.

Seeing couples as well as individuals

You are welcome to come alone or with your partner, whichever feels right. Sexual difficulties are frequently experienced by both people in a relationship, even when only one of them has the symptom, and involving a partner can make a real difference.

There is no expectation either way, and nothing is discussed with your partner that you do not want discussed.

What an appointment involves

We start with a conversation — unhurried, and at whatever pace suits you. I will ask about the problem itself, your general and gynaecological health, and how things have developed over time.

An examination is often helpful, particularly where there is pain, but it is never done without your agreement and can be deferred to another visit if you would prefer. Nothing happens that you have not consented to.

What can help

Treatment depends entirely on what is found, and often combines approaches:

• Treating an underlying physical cause such as a skin condition, endometriosis or infection
• Vaginal oestrogen or moisturisers where dryness is the issue
• Pelvic floor physiotherapy, which is highly effective for muscle-related pain and tightness
• Graded approaches using dilators, with proper guidance
• Referral for psychosexual therapy or couples therapy where that is likely to help
• Reviewing medication that may be contributing
• Straightforward practical advice, which is sometimes all that is needed

Please do raise it

If there is one thing I would like women to take from this page, it is that you do not need a dramatic problem to justify the appointment, and you will not shock me. This is ordinary clinical territory, discussed matter-of-factly and in complete confidence.

We need to talk about this more, not less.