1. FFSRH Member of the Institute of Psychosexual Medicine
Dr Gillian Vanhegan
FFSRH
Member of the Institute of Psychosexual Medicine

2. Session Five Recognising female sexual problems
Deep and superficial dyspareunia
Loss of libido
Orgasmic disorders
Primary or secondary vaginismus
Vulvodynia

3. Causes of deep dyspareunia
Gynaecological
PID
Endometriosis
Ovarian cysts
Fibroids
Malignancy

4. Causes of deep dyspareunia
Bowel problems
IBS
Crohns/ulcerative colitis
Constipation
Malignancy
Other
Bladder infection, musculoskeletal, pelvic adhesions

5. Causes of superficial dyspareunia
Infections
Candidiasis, HSV, TV, BV
Dermatological
Eczema, Psoriasis, Contact dermatitis
Lichen Sclerosis, Lichen Planus
Behcets

6. Causes of superficial dyspareunia
Surgical/traumatic
Episiotomy and tears
Radiotherapy and excisions
FGM
Others
Malignancy
Anatomical

7. 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

8. Orgasmic disorders Different types of orgasm
Penetrative and non penetrative
Helping the patient to be realistic

9. 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.

10. 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

11. 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

12. 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

13. Covert Presentations Avoidance of examinations Feeling dirty
Undressing
Getting on the couch
Attitude on the couch
Engaged or not

14. Female Life Events Child Abuse Domestic Violence
Separation/Divorce/Death
Abortion
Child Birth
Breastfeeding

15. Female Life Events (continued)
Medical interventions
Swabs/Smears/Colposcopy
Surgery
Mastectomy
Hysterectomy
Vulvectomy
Stomas

16. 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

17. 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

18. Next session The final session Reflection Evaluation What next
Training options