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.

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.

Sex can become an obsession, compulsion or addiction, and can be used like any other addictive substance such as alcohol or drugs, to alter your state of mind. Sex makes us feel better, partly because it reduces anxiety, causes a surge of hormones, and feels pleasurable. When the need for those effects becomes a powerful driving force in a person's life, then the possibility of developing an addiction arises.

People become addicted to a range of sexual activites, such as visiting prostitutes and sex shows, masturbating, with or without using pornography, compulsively seeking love and relationships, fantasising about sex rather than living life in the present.

It is very common that sex addicts become addicted to other substances or compulsive behaviours to mask or to support the sex addiction, which is often their main and primary addiction. Alcohol, drugs, and gambling are examples of other addictions which may be used in this way.

The addictive behaviour can become strictly ritualised, and days or weeks may be spent planning the next event or activity. Once it has been acted out, the compulsion subsides for a while, and then the mind starts planning the next one, and the cycle starts over again.

Now there are three of you and you have become a family, many aspects of your relationship are likely to change. Your status within your wider family and friends will be affected, and people who are not parents may find it odd that you seem so preoccupied with your child. This may change your friendships and social life. As you walk in the street with a baby, people like to stop and admire him or her. This can feel very supportive, or at times a bit of a nuisance.

Between you there will be much less private time, and less energy for your relationship. Intimacy may be more difficult, and sex may be on the back burner. The importance of communicating, understanding and accepting what cannot be changed about the situation cannot be stressed enough! At least you can remind yourselves that with a baby everything is "only a phase", as things change so fast.

It is important for the two of you to get private time away from the baby as soon as you can, even if it is only an hour to go for a walk. If the baby sleeps with you at first, make sure that when your child has his or her own room that you teach them about the importance of your privacy, and the meaning of a closed door. Some parents prefer to give the children free and open access to them at all times, and are not concerned for their privacy.

Firstly the fear of another pregnancy may be important, so careful attention to contraception is a must. Fear of causing pain or further damage can affect both partners sexually, even causing erection problems.

There may be "flashbacks" to the scene of the birth, reminding both partners of the difficult, painful or frightening experience, and re- awakening the emotions attached to the events.

It may feel to the mother that her sexual parts have given her so much trouble that she wants nothing more to do with them. Alternatively, she may feel that her sexual parts now belong to the doctors and to the hospital.

It can be very important for a couple to talk through what they remember of events, and share the feelings about it. There may be a sense of loss that they did not have a simple birth like others do, or even a feeling of having failed in some way. A lot of the feelings are very natural, a bit irrational, and need to be talked about and shared.

There seems to be an increased risk of Post Natal Depression after a difficult birth, so extra vigilance and care is needed. Health visitors and general practitioners will help with this, as they are well aware of how awful that can make you feel. Do consult your health visitor if you are at all worried about your mood.

Sexual changes in the mother
The commonest change is loss of sexual desire. A very large majority of mothers notice it, and it may take up to a year to return to anything like normal. In some women, whilst it comes back to some degree, it does not return to its pre-pregnancy level, and reduces after each child. It may be partly due to the hormone changes that go with childbirth and breast feeding. In some women it is a normal sign of their adjustment from woman to mother.

For some women intercourse is mildly painful, and they have a dull aching sensation which can persist for many months. Provided healing is complete, the pain is not a reason to avoid intercourse and it does not mean that anything is wrong. Things can take a while to settle down.

Another change is slowing down of arousal, possibly because of changes to the layout of the genital area, needing a different type of touch. The vagina may be less tight and give less friction. Fear of pain after stitches may interfere with arousal. Worries about contraception, or fear of another baby too soon will also slow down arousal.

Orgasm may be delayed, partly due to any of the above, and also due to changes in the way the clitoris is positioned. Changes of sexual position or angle may help with this.

Emotional changes in the new mother
After the emotional high of delivering your baby, the anxieties and tiredness begin to be felt. Actually caring for the tiny helpless creature can make you feel emotionally raw, and because the baby's feelings are so strong and uncontainable, they can have the effect of making the mother a bit babyish in her own feelings. This may show in a need for reassurance from her partner, unexplained tearfulness, or emotional instability. She may feel the urgent need to have her own mother around.

Another emotional change is the shift from woman to mother. Suddenly there is 24 hour demand, and she has to meet it or see that somebody else does! The responsibility can seem to change her attitudes and values. "You're no fun any more" is a common cry!

Exhaustion can make it hard to know exactly what you do feel, and exhaustion is a very common part of adjusting to parenthood. After a while, many couple with one child find life can carry on quite a bit as before, but after the second baby, they really notice the difference.

Finding any emotional energy left for lovemaking is a major change for some women. After being at the baby's command, a request for intimacy of any kind can feel impossible to meet.

Firstly, the changes which are most obvious are to the body shape. Post natal exercises will help improve muscle tone and repair the stretching to the pelvic floor. A return to the normal exercise regime when possible should restore the outline to something approaching the pre-pregnancy shape, but few women retain their waist measurement precisely, so expect to increase by a few centimetres with each baby.

Less obvious changes are those which happen in the genital area, both within the vagina, and the other sexual parts. The clitoris may be in a different place relative to the vagina. This can mean you have to adjust your position to get an orgasm.

Some women find intercourse causes a dull aching sensation for a few months, and even as long as a year. Provided healing has occured there is no reason to stop making love if you want to. Imagine all the changes to the muscle structure, and it is clear that recovery from that may take time.

Inside the vagina there may be little crevices and crannies which are new. They are normal, and you may find after a bath that a little water is retained so drying is important. Also, the vagina may feel less tight than before, so the amount of friction for each partner may be less. This could mean the time taken to have an orgasm may be longer.