They are among the most common reasons for women to see their GP: gynaecological conditions. And in most cases, it’s a matter-of-fact type of conversation, no different to many others we have in the clinic. But, for myriad reasons, not every patient is quite so confident. Indeed, recent Government-backed research suggests up to one in three women don’t feel comfortable discussing such things with healthcare professionals.
In our experience, not unusual for a patient to struggle when trying to describe exactly where a problem is – sometimes using euphemistic, general terms like ‘down there’. As doctors who spend a lot of time treating women’s issues, we understand why.
The female genito-urinary system is a marvel in its complexity: producing eggs, nurturing a foetus, as well as giving women sexual pleasure and eliminating waste such as urine. But unlike men’s genitals, most of it is neatly tucked away so it’s not exactly easy to see what’s going on.
And there are, some might say, design flaws: the urethra (the tube which passes urine out from the bladder) is short, and close to the vulva and rectum, for instance.
It can be hard to know where the symptoms are coming from, particularly if it’s pain or itching, and a problem in one area can quickly spread to another because bacteria can be easily passed around. As we get older – particularly from mid-life and beyond – there is so much more that can go awry.
You can largely blame the menopause. As levels of oestrogen fall, the skin around the genitals and in the vagina becomes thinner and more fragile – more prone to infections, prolapse, dryness and pain. Women often put up with these problems, enduring painful sex, incontinence or recurring infections, all because they think it’s a normal part of ageing.
But that’s not the case. There is no need to suffer in silence. Anything new or unexpected should always be investigated by a GP, nurse or gynaecologist – if only for some reassurance.
Many women are understandably worried about cancer – one in 41 women in the UK will be diagnosed with womb cancer at some point and one in 50 with ovarian cancer. But it’s not the only reason for worrying symptoms.
In fact, it’s far more likely it’s something else which is much simpler to treat…
Intimate itch? Then a hormone gel can help
An intimate itch can be a distressing issue for about eight in ten women after menopause – although few will talk about it. But if your vagina feels dry, itchy or sore and there’s a burning discomfort, and you’re over 40, you could be suffering from the genito-urinary syndrome of menopause. Also called vaginal atrophy, the vagina becomes dry from the lack of oestrogen and is less acidic. There’s also less of a substance called glycogen produced, which has a role in the growth of healthy bacteria.
All of this can cause itching, pain and discomfort during sex, and can increase the risk of urinary tract infections. The first thing to do is to stop using soap or fragranced cleansers. Pat – don’t rub – after a shower, wear cotton underwear and avoid tight clothing.
Products aimed at relieving vaginal itching work by numbing the discomfort rather than treating it, so doctors don’t generally recommend them. Instead, use a vaginal moisturiser to relieve the dryness (some are available on prescription) and a lubricant is essential for reducing friction during sex.
The thing which can be life-changing, though, is vaginal oestrogen. Some doctors believe it’s so important that all women should use it, even before they have symptoms. It comes as a cream, gel or pessary and does not have the same risks and side effects as HRT because it isn’t absorbed into the rest of the body.
For most women, it’s safe to use, although those with some forms of breast cancer should avoid it. If this might be you, speak to your GP or specialist. You can get it on prescription or over-the-counter following a consultation with a pharmacist.
Other causes of itching include thrush, caused by an imbalance of a fungus called candida. You can buy antifungal creams, pills and pessaries from the chemist to treat it, but also change your bathing habits as above and try to avoid tight-fitting, synthetic clothes that can make you hot and sweaty, irritating the area.
You should also see your GP to rule out other issues if you suspect thrush but are post-menopause. Although taking HRT can make you more prone, it’s less common once your periods have stopped. If it comes back more than three or four times a year, see your GP for investigations.
White patches could be linked to cancer
If you have white patches on your genitals it could well be lichen sclerosus. This is an inflammatory condition which causes tremendous itching and is mostly diagnosed in women aged between 40 and 60. It isn’t contagious or sexually transmitted, but the pain and discomfort it causes when urinating or having sex can have a huge impact on women’s lives and their relationships. The skin down there might look very smooth – almost shiny – and may even bleed when touched. It can also cause the entrance to the vagina to narrow.
Lichen sclerosus is thought to be an auto-immune condition in which the body mistakes the skin for foreign tissue and attacks it. Treatment includes high-strength steroids and medical moisturising creams – but if there’s no improvement or any thickening, or ulceration lasts for more than two weeks, go back to your GP. One in 20 cases develop into vulval cancer, so it’s important to get it treated and to get any lingering issues checked out.
Know your normal and don’t ignore changes
It is normal to have vaginal discharge, but if it changes colour or develops an unusual odour – anything that’s not normal for you – then it might indicate a problem. Changes like these could indicate a sexually transmitted infection called trichomonas.
We get lots of women in our clinics who have been with the same person for decades but then are separated by death or divorce. They get a new partner and come to us with worrying symptoms. For the first time in their lives, they’re getting STIs – and they are not alone.
The number of STIs being diagnosed in older adults has increased by about 20 per cent since 2014 – in fact, the largest increases in gonorrhoea and chlamydia are in the over-65 age group.
Changes to discharge can also indicate an overgrowth of bacteria called bacterial vaginosis. This is not an STI, but some women find it is triggered by sex. To treat it, an antibiotic gel or cream which can be bought over the counter, or you can take a dose of antibiotic metronidazole.
If discharge is blood-stained it might be an STI such as chlamydia or gonorrhoea, which again is treated with antibiotics. Blood might also indicate a cervical polyp – a benign growth on the wall of the cervix which can be removed under local anaesthetic. If you’re bleeding between periods, after sex or after menopause, it should always be checked out.
When taking sequential HRT – cycles of two weeks of oestrogen and two weeks of oestrogen and progesterone, usually given to women still having periods who are in peri-menopause – bleeding is expected. But with continuous HRT – taken daily without a break – you shouldn’t bleed after about three to six months.
If you do, it could indicate thickening of the womb lining, known as endometrial hyperplasia. This is benign but needs monitoring as in rare cases it can lead to womb cancer.
Simple and fun ways to have a pain-free sex life
Women who find sex more painful as they age can sometimes develop a condition known as vaginismus. This is an involuntary spasm of the vaginal muscles – linked to the brain associating sex with pain – which can make penetration painful or even impossible. First of all, use lubricant – it’s everyone’s best friend when it comes to sex.
The next step is vaginal dilators, which are tube-shaped devices that come in a range of sizes. Using these, along with pelvic floor exercises, can help to regain control of the muscles. When used in combination with sex toys, they can also rebuild the association with pleasure. Details of these can be found at jodivine.com.
Very heavy periods? Go and see your GP
Some peri-menopausal women find they have heavier, longer periods. This can cause fatigue because the body stores less iron and is linked with brain fog and poor concentration.
How heavy is too heavy is up to you to decide – no one will ask you to measure it. But see your GP if you’re soaking through sanitary protection regularly or are having to use both tampons and pads, as you may need iron supplements or medication.
There are ways to tackle a prolapse
Pelvic organ prolapse is when one or more organs in the pelvis slip out of their usual position. Think of your pelvic floor as a hammock holding everything from your womb to your bladder and bowel in place. As we grow older – and particularly after having babies, putting on weight and reaching menopause – those muscles loosen and things aren’t held as tightly in place.
If something has moved, you might feel a heavy, dragging sensation in the pelvis or inside the vagina. It might also feel like there’s a golf ball up there or you may see a bulge or lump. Sex can become painful and you may struggle to empty your bladder or bowels properly.
Sometimes, simple lifestyle changes such as losing weight, stopping smoking, avoiding constipation and pelvic floor exercises can help. There are also non-surgical interventions such as a pessary or a shelf pessary – which is like a doughnut inserted into the vagina to hold everything in place. Vaginal oestrogen can also help ease some symptoms. If none of these is successful, surgery can be considered to stitch the organs back into place or support the muscles.
Burning pain that may be a urinary infection
Burning pain in the genitals, discomfort in the lower abdomen and the need to urinate frequently are some of the classic symptoms of a urinary tract infection (UTI).
They affect 1.7 million people a year in the UK, most of them women, and are generally easy to treat with antibiotics. But in some cases, they can recur. This can be a result of uncontrolled type 2 diabetes and other underlying problems, which should be checked by your GP. Otherwise, we use a low dose of daily antibiotics, taken long-term, and urinary antiseptic tablets to prevent harmful bacteria from growing.
In a very small number of cases, recurrent symptoms can be indicative of ovarian cancer, so a GP may send you for a scan, just to be sure.
A wee problem is not just a part of ageing
Incontinence – the involuntary emptying of the bladder – affects at least one in five women over 40 in the UK, although most don’t talk about it. It is NOT a normal part of ageing. So if you’ve stopped exercising because you’re afraid of a leak, you can’t cough or sneeze without wetting yourself, or you need to run to the toilet at the first sign of needing to go, speak to your GP.
Stress incontinence is the most common, with leaking during any physical activity that increases abdominal pressure – coughing, sneezing, laughing or exercising. This happens because of weakened pelvic floor muscles. Urge incontinence is when you feel a strong need to go and don’t make it to the toilet in time. It is often related to an underlying condition called overactive bladder syndrome.
Pelvic floor exercises to help strengthen the muscles are the main treatment for stress incontinence. If they don’t work, you might need a referral to a women’s health physiotherapist who may use various devices to help train the muscles. A medication, duloxetine, can also be used.
And for an overactive bladder, injections of Botox or medication to relax the bladder may be helpful. Vaginal oestrogen can be useful for both types. PS… there’s no need for intimate washes
Your vulva and vagina are supposed to have an odour. Vaginal discharge isn’t dirty and neither is menstrual blood, which means you do not need to wash inside your vagina. It already has a wonderful balance of bacteria which naturally maintains a slightly acidic pH and stops other, more harmful bacteria from coming in.
So don’t use soap and don’t use products even if they say they’re suitable for vaginal cleansing. Just leave it alone. The skin there is much thinner and more prone to irritation compared with the rest of the body. If you upset the pH balance you’re more likely to cause a problem like thrush or bacterial vaginosis.
Wash with water and just on the outside – you don’t need to direct anything up your vagina. For the same reasons as above, avoid using talc, baby powder, wipes or intimate deodorants.