The menopause is a time when previously unacknowledged sexual difficulties become harder to deny, when physical changes give rise to sexual problems, and when the end of fertility brings the whole matter of women’s sexuality into high relief. Some see this period as an opportunity to give up an activity that may never have been particularly enjoyable or satisfying, whilst others feel that, with children away from home and no risk of pregnancy, a new sexual relationship can develop. There seems some pressure from the media to remain sexually active and attractive, when in truth desire and enjoyment may have gone.

Mandy, age 38, was fed up with Tony as he complained all the time about her loss of sexual desire. They had been together sixteen years, and he kept waiting for her to be sexy again like she was before they had any children. They had Patrick, age 15, and Gemma, age 12. She could be sexy for a few days, but then something would upset her and she would turn off. It would be several weeks before she would be feeling sexy again.

Assessment

The therapist helped the couple to see the pattern of behaviour that turned Mandy off. Tony did not realise that he was aggressive when drunk. He thought it was just a bit of fun. He also did not realise, because Mandy had not told him, that Patrick was getting rude and upsetting Mandy, his teacher, and Gemma. The couple began to feel closer to each other as they discussed these things.

Increase Sexual Awareness

For Mandy the whole topic of sex was difficult as she had bad experiences with har family's attitudes in the past. These experiences were preventing her from feeling good about herself, and from feeling OK about sex. The therapist helped her to get over her past, and allow herself to feel sexy if she wanted. Also, it became clear that Tony wanted more sex than she did, because it was the only time he felt close to her.

John and Jane came to see me together. The immediate problem was that Jane, aged 38 years, urgently wanted a baby. John, who was 43, was willing to have a child but was completely ‘off’ sex. They had not had sexual intercourse for more than a year. However, John described himself as being turned on by other women - but he chose to stay faithful to Jane.

Jane’s childhood was spent in a loving family where physical warmth and emotional expression were freely given and received. At school Jane was a high achiever and went on to university after which she made a succesful career as a journalist. In her adolescence Jane's Father, who was a Doctor, developed bouts of intense anger. Jane found this very frightening, although the anger was directed towards her Mother. She remembered that her Mother always gave in to her Father on these occasions.

John’s childhood was more difficult. There were long periods when his Father was absent from home. Emotions were constrained and little physical affection was shown him by his Mother. He, like Jane, was highly successful at school and university where he gained a good History degree. It was at university that John and Jane met. John was very taken with the easy going affection that Jane showed and Jane loved him for his quiet steadiness and attentiveness to her. They were constant companions, sexually excited and satisfied by one another.

Diana, age 31, had a baby girl nine months ago. It had been a difficult birth, and she had very bad Depression afterwards. Her mother had to help with the house and the baby, as Diana could not cope. She had anti depressants, which helped a lot, and got a bit better. When she and Edward started to have sex again, she was not that keen on it. She also had a sharp pain in the back wall of her vagina.

Assessment

Because she could describe the position of the pain so well, the therapist asked her to see her doctor. The doctor pressed on the back of the vagina, and caused exactly the same pain. She referred Diana back to the gyneacologist.

Treatment

The gyneacologist found a little sore tag left over from having the baby. The vagina had healed up, but a little bit was in the wrong place and giving the pain. Under general abaesthetic, the tag was removed.

Afterwards

No more to say. No more pain for Diana. The depression lowered her sexual desire, so she and Edward did not have so much sex as before, but it was OK. Once the depression was past, her desire came back, but not to the level of before the baby. This is normal for many women.

The most important thing about treatment is to make sure you know what the cause is. There are a number of reasons for pain in the lower body and the vagina, and if the cause is not found, you could have the wrong treatment.

First Step

As a start, see your doctor. If you have had a baby recently, see your gynaecologist. There can be tiny folds or cracks or bits of a scar which can give bad pain.
Visit a Well Woman Clinic if you have not had a check up for a while. Go to the Genito Urinary Clinic if you think it would be wise to have a total check for any infection They are very expert, completely confidential, and will treat anything that is going on. If you have vulval pain that seems not to be any of these, it could be one of the vuvlval pain syndromes, like Vulvodynia.

 Visit http://www.vulvalpainsociety.org for more information.

If all is well Medically...

1. The most likely reason is that you are not turned on enough when you have sex. See Arousal Difficulties for more about this.
2. Another reason is that the relationship you have is not working for some reason and you are angry but not showing it.
3. The pain may be "in your head". People think this means you are making it up, but it is a real pain. It is very likely to get better with Sex Therapy and a therapist will take you through this at a pace which is right for you. Any hidden bad feelings that you have, can be talked about and got better in the therapy.

For women sex is often about finding a partner and a relationship. Feeling close and warm is more important for women than it is for men. The stages of the sexual response cycle are arousal, orgasm and resolution .

Arousal

This starts with excitement, and then then reaches a plateau. In the excitement phase an increase in the blood flow to the sexual parts causes the sexual lips and the vagina to enlarge. The vagina becomes wet inside. The speed and strength of arousal vary greatly.

The plateau is a steady state of high arousal, just before orgasm. It needs a little more exciting touch to tip over into knowing you are going to come. Sometimes rubbing near the clitoris helps this.

Orgasm

This is an intense pleasurable sensation in the area of the sexual parts, with rhythmic spasms of the wall of the vagina and the other sexual organs. The skin may flush as well. Some women are able to have a number of orgasms one after another. Every woman is different when it comes to orgasm. Some have very strong orgasms, and others do not have any orgasm at all. Both are normal.

Resolution

This is when everything goes back to its usual state before you became aroused. The longer a woman has been aroused, the longer it takes to go back. If the woman does not have an orgasm then it takes even longer.

If you have noticed a change in your level of sexual desire, it may be a normal effect of stress or tiredness, chronic pain and illness, or simply that you are getting older. Loss of a close relative or loved on is a very natural reason to lose sexual desire.

Loss of desire in these cases, except for during bereavement, can be improved by increasing the time you spend thinking about sex, inventing some new fantasies, trying new things with your partner,and masturbating more often, but not so often that your ability to be sexual in other ways is impaired. During bereavement, you just have to wait until your mourning is over.

If you are in a relationship, it is really important to talk things over with your partner. There may be hidden anger or resentment which are the commonest reasons for reduced desire with a partner. If your partner is angry with you, you may pick it up at an unconscious level, and be affected by it. If you are angry with your partner, the same thing can happen. Partners often blame themselves, thinking they are no longer attractive to you, or that you don't love them any more.

If talking to each other is too difficult, a therapist could help you get the ball rolling.

The first part of overcoming Premature Ejaculation is thinking about the situation and how it is affecting you. Think what makes it better or worse, and any self help you have tried. It can be useful to talk over your previous sexual history with a therapist. Family traditions and ideas about sex may also be important.

One thing to remember is that usually there is nothing wrong with the penis.

Once the underlying causes of the difficulty have been addressed your therapist may prescribe sex therapy exercises, with special training work for ejaculation. These will be slightly different according to whether you have a partner willing to join in the therapy or not. The two main techniques for therapy are the Squeeze Technique and the Stop Start Technique.

There are various drugs which can help with this problem, and using them alongside the practical techniques can be really effective. Sometimes the medication on its own can be enough.

Greg is a 24 year old with a lifelong fear of sexual penetration. Ever since he became aware of his own sexuality he has known that he has not wanted to have intercourse. He says that he is heterosexual and that all his fantasies are about women. He can masturbate to these and has had a series of girlfriends - with whom he has been sexually active. He can achieve penetration, but is aware of a general anxiety that sweeps over him. He says that he prefers his girlfriend to masturbate him with her hand, or that they masturbate themselves in from of each other.

He and his partner Joanna want to get married and start a family. Greg wants to deal with his problem. Joanna thinks that Greg is frightened of being intimate with her, and possibly not wanting to make a commitment to marriage. Greg denies thus, and they have both argued a lot about this before coming to see a therapist.