There are many causes of sexual difficulty. Whilst it is worth knowing about some of the predisposing factors, a preconceived idea about the aetiology may be misplaced. For example, one woman who had a traumatic delivery with a third-degree tear may find intercourse painful and lose her libido. She may have a residual misconception of damage after all has healed. Another patient with the same presentation may have lost her libido because her husband had an affair whilst she was pregnant. It is impossible with human behaviour to extrapolate from one person to the next. A general practitioner may have previous knowledge of a patient and her family. This is often helpful, but can be a hindrance if it leads to a theory of “causality”. Sometimes a patient will especially seek out a new doctor or locum in order to talk about what may seem to them to be an embarrassing problem. They may then return to their regular doctor when all is well. When a difficulty is resolved, they may not want to discuss it with the doctor and any enquiry will then seem prurient.
First – do no harm
Even if all doctors are not equipped to treat sexual difficulties they can at least make sure that they do not produce iatrogenic problems. We need to be careful how we speak to patients. “Throw away” remarks by careless professionals can be the seed that causes the growth of a fantasy in a patient’s mind. Statements to women such as, “You look tight”, or “Your vagina is loose”, or “You have a nasty erosion”, can lead to fantasies about the body and its function. The way in which we examine women is important. Many women have been traumatized by rough speculum examinations, often done when younger, to achieve an unnecessary smear. They may develop fear of vaginal examinations that may spread to their sexual lives.
Gynaecological problems predisposing to sexual difficulties
Gynaecological problems and interventions may also cause sexual and psychosexual difficulties. Dyspareunia may be a symptom of endometriosis, pelvic inflammatory disease, ovarian pathology and other non-gynaecological diseases such as irritable bowel syndrome. If no pathology is found and no pain elicited on vaginal examination, then the professional must look elsewhere for the aetiology. Sometimes a physical cause can lead to vaginismus even after the initial condition has resolved. Fear of pain can lead to muscle tension – vaginismus – which is itself painful, leading to the belief that there is still something wrong. A simple explanation of the chain of events combined with sensitive examination by the doctor and self-examination by the patient can help to break this vicious circle.
We regularly ask patients about other aspects of their lifestyle such as exercise, sleep, or hobbies, but neglect to ask them about sex or warn them about the effects of our interventions. If sex has been satisfactory before hysterectomy, it will usually continue to be so afterwards, especially if a cause of discomfort or bleeding has been removed. In a prospective study, 1101 women who underwent hysterectomy were surveyed at 12 months and 24 months. The results showed that the percentage of women who engaged in sexual activity increased, the rate of dyspareunia and anorgasmia declined, libido increased, and fewer women reported vaginal dryness following hysterectomy.
After hysterectomy some women fantasize about the shape of their bodies and what has actually been removed. Poor knowledge of anatomy and the process of the surgery may lead to misunderstandings. Some women may think that the residual vagina is tight or small, whilst others may think that their vagina is voluminous, stretching up into the abdomen. It is worthwhile asking about sex at the 6-week postoperative check-up and performing an examination if there is any problem. This is another situation in which the encouragement of self-examination can help dispel fantasies about the remaining anatomy. Women need to know that intercourse may feel different both for them and their partners, especially if the uterus was enlarged before surgery.
Removal of the womb has an emotional component and some women may feel stripped of their femininity. There may be anger about the surgery and feelings that it was perhaps done without due discussion, especially if a woman, whatever her age or parity, has a deep-seated desire for more children. There may also be fears that the organs of sexual pleasure have been removed. Reassurance that this is not the case and that arousal and orgasm are still possible and permissible may be all that is necessary.
Other gynaecological operations
Women may fear that they will not be able to have sexual intercourse after a vaginal repair. general practitioners need to establish whether the woman is still sexually active, even if she is very elderly, before referral for surgery, and the woman reassured that penetration will be possible postoperatively. If a woman has had repeated pelvic surgery, e.g. for endometriosis, there may be residual pain from adhesions. This may lead to dyspareunia and even to vaginismus. Women who have been repeatedly examined by doctors may feel that their bodies are no longer their own. Residual pain may also be of an emotional nature and it may be difficult to enable the patient to make the mind/body link. Once again a sensitive genital examination and encouragement of self-examination, whilst being aware of the woman’s feelings, are the keys to helping these patients.
Events such as termination of pregnancy, miscarriage, and colposcopy may have deep emotional significance and associated guilt. Relationships may be strained and there may be depression. All these emotional factors, plus the fact that women’s bodies have been submitted to examination and manipulation, make these procedures potential danger zones for psychosexual problems.