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Are your female intimate health problems worth worrying about? Doctors reveal the signs of cancer every woman should know - and the 'life-changing' medication that can make sex enjoyable again, in our ultimate guide
They are the very intimate issues that few women like to discuss – let alone bring up with their GP.
From itching 'down there' to problem rashes, dryness, pain during sex and colourful discharge, there are myriad complaints affecting women's genitals which are all too often overlooked or endured.
Some can be prompted by hormonal changes linked to perimenopause or menopause which begin to affect women in mid-life from their 40s onwards.
As levels of the sex hormone oestrogen fall, the skin around the genitals and in the vagina becomes thinner and more fragile – more prone to infections, prolapse, dryness and pain.
Whatever the cause, anything new or unexpected should always be investigated by a GP, nurse or gynaecologist
Other issues are simply a side effect of women's unique anatomy which has, experts say, several 'design flaws'.
The urethra (the tube which passes urine out from the bladder) is short, and close to the vulva and rectum, making it easy for bacteria to spread around.
Because everything is so close together, it can also be hard to see what's going on or for women to pinpoint precisely where a problem is occurring.
As GP Dr Philippa Kaye, an expert on women's health issues, explains: 'The female genito-urinary system – as we call it – is a marvel in its complexity: it produces eggs, nurtures a foetus, gives women sexual pleasure and eliminates waste 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.
'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.
'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.'
Whatever the cause, anything new or unexpected should always be investigated by a GP, nurse or gynaecologist – and you should never be embarrassed to discuss something you're concerned about.
And most issues are not only extremely common but easy to treat.
Here, we spoke to the experts to find out everything that can go wrong – and what you can do to fix it.
Intimate itch? A hormone gel can help
An intimate itch can be a distressing issue for about eight in ten women after the 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 genito-urinary syndrome of the menopause, also called vaginal atrophy.
'The vagina becomes dry from the lack of oestrogen and less acidic,' explains Dr Kaye. '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.'
Dr Kaye says the first thing to do is to stop using soap or fragranced cleansers.
'These can all irritate the delicate skin down there,' she adds.
'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.
What can be 'lifechanging', says the Mail's GP columnist Dr Ellie Cannon, is vaginal oestrogen.
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,' adds Dr Cannon. 'If this might be you, speak to your GP or specialist before using it.'
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, says Dr Kaye.
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 don't assume it's important not to ignore them – it could be the early signs of something serious.
Experts say that many patients wrongly assume that white patches are a sign of a sexually transmitted disease, meaning they are often too embarrassed to tell their partner – or their GP.
However, in most cases, this symptom will be due to a condition called lichen sclerosus – an inflammatory condition which causes tremendous itching.
It 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. It can also cause the entrance to the vagina to narrow.
'It's phenomenally itchy, and the skin might be easily damaged and bleed if you touch it,' says Dr Cannon. 'You'd feel the need to itch even in public, which can feel terribly embarrassing.'
Lichen sclerosus is thought to develop when the immune system mistakes the skin for foreign tissue and attacks it. Treatment includes high-strength steroid 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, Dr Cannon recommends.
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
Causes of itching can include thrush, caused by an imbalance of a fungus called candida
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 you might have a problem which warrants a visit to the doctor.
Changes such as 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,' says Dr Kaye.
'They get a new partner and come to us with worrying symptoms. For the first time in their lives, they're getting STIs.'
It's becoming increasingly common: 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,' explains Dr Cannon. 'To treat it, you can buy an antibiotic gel or cream 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.'
Always get any bleeding between periods checked out, or if you bleed after sex or after you've gone through the menopause.
Some bleeding 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 – can be expected.
But Dr Kaye says if you're on continuous HRT – taken daily without a break – you shouldn't bleed after about three to six months.
'That could indicate thickening of the womb lining, known as endometrial hyperplasia,' she says. 'This is benign but needs monitoring as in rare cases it can lead to womb cancer.'
Simple and fun ways to 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,' says Dr Kaye. '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
See your GP if you're soaking through sanitary protection regularly
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,' says Dr Cannon. '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.
But as we grow older – and particularly after having babies, putting on weight and reaching the menopause – those muscles loosen and things aren't held as tightly in place, Dr Cannon explains.
'If something has moved, you might feel a heavy, dragging sensation in the pelvis or inside the vagina,' she says. '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 and avoiding constipation can help.
But all women should also learn how to do pelvic floor exercises, Dr Cannon recommends.
'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,' she adds. 'Vaginal oestrogen can also help ease some symptoms.'
If none of these are 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 1.7million 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, Dr Kaye explains.
'This can be as a result of uncontrolled type 2 diabetes and other underlying problems, which should be checked by your GP,' she says. 'Otherwise, doctors will prescribe 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 exercise. 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 is 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 organ may be helpful. Vaginal oestrogen can be useful for both types.
P.S... 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,' says Dr Kaye.
'It already has a wonderful balance of bacteria which naturally maintains a slightly acidic pH and stops other, more harmful bacteria 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.'
Your skin down there is much thinner and more prone to irritation compared with the rest of the body, she adds, which means 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,' Dr Kaye says.
For the same reasons, also avoid using talc, baby powder, wipes or intimate deodorants.
How to give your vagina a quick MOT
If you learn what your vagina looks like normally, it will be easier to pick up anything unusual if it develops.
Dr Kaye recommends washing your hands and finding somewhere quiet where you won't be disturbed, with a mirror and a torch.
'Sit wherever you're comfortable, which might be with your back against a wall or pillow, and pull your heels into your bottom so your legs are like a diamond.
'Then use the mirror and torch to explore the whole area. Make sure you spread your labia and check the skin inside.'
Check for discolouration on the skin, for any patches which are itchy or sore, lumps and bumps, rashes and moles.
'Note down anything unusual and, if you perform these checks regularly, you'll be able to see whether it has changed or worsened,' says Dr Kaye. 'And get any concerns checked out by your GP.'