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Dr Gillian Vanhegan. FFSRH Member of the Institute of Psychosexual Medicine. Session Five. Recognising female sexual problems Deep and superficial dyspareunia Loss of libido Orgasmic disorders Primary or secondary vaginismus Vulvodynia. Causes of deep dyspareunia. Gynaecological PID
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Dr Gillian Vanhegan FFSRH Member of the Institute of Psychosexual Medicine
Session Five • Recognising female sexual problems • Deep and superficial dyspareunia • Loss of libido • Orgasmic disorders • Primary or secondary vaginismus • Vulvodynia
Causes of deep dyspareunia Gynaecological • PID • Endometriosis • Ovarian cysts • Fibroids • Malignancy
Causes of deep dyspareunia Bowel problems • IBS • Crohns/ulcerative colitis • Constipation • Malignancy Other • Bladder infection, musculoskeletal, pelvic adhesions
Causes of superficial dyspareunia Infections • Candidiasis, HSV, TV, BV Dermatological • Eczema, Psoriasis, Contact dermatitis • Lichen Sclerosis, Lichen Planus • Behcets
Causes of superficial dyspareunia Surgical/traumatic • Episiotomy and tears • Radiotherapy and excisions • FGM Others • Malignancy • Anatomical
Sexual problems • Loss of libido can be due to many factors, such as loss of interest in the relationship, mistreatment in the relationship, hormonal changes, especially at the menopause. Failure to communicate her needs in the relationship
Orgasmic disorders • Different types of orgasm • Penetrative and non penetrative • Helping the patient to be realistic
Vaginismus • Vaginismus is a strong contraction of the vaginal muscles which is not under the conscious control of the woman. • It is a symptom of internal distress and a subconscious need to prevent penetration of her private self.
Vulvodynia • Vulvodynia means pain in the vulval area and can occur as a means of stopping penetration. • It often occurs as an expression of internal pain • It might be focussed at the vulva rather than other sites for expression of internal pain, because of something in the past history
Cycle of Pain • Body anticipates pain (fear/anxiety) • Body automatically tightens vaginal muscles • Tightness makes sex painful or impossible • Pain reinforces reflex response • Body reacts by bracing more • Avoidance of intimacy and lack of desire
Covert Presentations • Repeated swabs • Dissatisfaction with contraception • On the pill to control periods • Can the pill make you go off sex? • Defended—not communicative • Inappropriate demeanour/dress • Avoidance of smears
Covert Presentations • Avoidance of examinations • Feeling dirty • Undressing • Getting on the couch • Attitude on the couch • Engaged or not
Female Life Events • Child Abuse • Domestic Violence • Separation/Divorce/Death • Abortion • Child Birth • Breastfeeding
Female Life Events (continued) • Medical interventions • Swabs/Smears/Colposcopy • Surgery • Mastectomy • Hysterectomy • Vulvectomy • Stomas
Psychodynamic treatment • Identify the D/P/R and reflect it back to the patient • Be aware of the unconscious feelings in the room • Be aware your defences and those of the patient
Psychodynamic treatment • Look at when/why or why not do a psychosomatic genital examination • Use the feelings to help the patient see her problem • Spend some time to reflect on the consultation with the patient and make plans for next steps
Next session • The final session • Reflection • Evaluation • What next • Training options
