Itching, baldness and painful sex: The embarrassing questions that you’re too shy to ask your GP

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We doctors are a fairly unshockable bunch. We’ve seen it all – multiple times, usually, and probably that same day. People talk of embarrassing ailments – often, but not exclusively, ones that involve our ‘private’ body parts or bodily functions. But it really is all in a day’s work for us.

Of course, I understand why some patients find these topics hard to talk about. But the big concern is when it stops them seeking any kind of medical help. Surveys suggest that up to two-thirds of Britons avoid visiting their GP for conditions they consider embarrassing. Many instead ignore their problems, hoping they’ll go away, but often they are unwittingly delaying diagnosis and treatment until things have worsened considerably.

Bowel and cervical cancer, for example, are frequently detected too late because many people don’t attend screening or see a doctor when they get worrying symptoms.

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Many patients find it difficult to talk about embarrassing ailments, but doctors are an unshockable bunch

Thankfully, most of the time it’s nothing that can’t be easily treated and, really, the worst part is knowing people have suffered in silence for so long. I often hear the phrase ‘I thought I was the only one…’ when it couldn’t be further from the truth. Most of these problems affect millions every year.

So in an effort to finally banish any awkwardness, over the next two weeks we will guide readers through some of the most common intimate problems, explaining the symptoms, causes and treatments. This week, I focus on conditions affecting women, while my GP colleague and Mail on Sunday columnist Dr Ellie Cannon tackles those that men most commonly suffer from.

Alongside our own in-depth knowledge, we’ve spoken to leading specialists for the very best advice. We hope it will help dispel the myths, arm you with the facts and give you the courage to pick up the phone and make that appointment with your GP.

THE ITCH THAT MANY WOMEN JUST PUT UP WITH… FOR YEARS 

Persistent itching – medically termed pruritus – anywhere on the body is uncomfortable. But when it affects an already sensitive area such as the vagina or vulva (the vaginal opening, labia and clitoris), it is particularly distressing.

About one woman in ten in the UK suffers long-term genital itching and, aside from the burning and irritation, it may also cause the skin to break, leading to bleeding and skin infections.

Sex can be so painful that some women avoid it altogether.

While it can affect any woman at any age, the dryness that causes the itching is more common in later life. I find it hugely frustrating when patients say they have put up with it for years, too embarrassed to seek help, or didn’t realise there was anything that could be done.

WHAT CAUSES IT?

Usually an itch is linked to dryness, says Paula Briggs, consultant in sexual and reproductive health at Southport and Ormskirk Hospital NHS Trust.

This is common around the time of the menopause, due to the lack of the hormone oestrogen which keeps the delicate membranes of the vagina and vulva supple.

But breastfeeding, use of the contraceptive pill, breast cancer drugs and other medications can trigger it too.

‘No one talks about dryness – it’s a massive taboo subject,’ says Dr Briggs. Indeed, a 2013 survey of British women found one in ten sought no treatment out of embarrassment, and 42 per cent ‘didn’t think it was important’. Dryness can also be due to a common skin condition called lichen sclerosus, where white, itchy patches form on the vulva. But left untreated, this can cause scarring.

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Breastfeeding is one of many things that can trigger persistent itching – medically termed pruritus

The cause is not known but scientists believe it may be due to a fault in the immune system leading to attacks on the skin.

On very rare occasions, an itch can be a sign of vulval cancer.

WHAT CAN I DO?

Dr Briggs says: ‘Dryness will go on for ever if it’s not treated. It’s a chronic, progressive condition, not like most menopausal symptoms, which will resolve.’

Thankfully, creams or pessaries containing oestrogen can improve the quality of the skin and reduce the itch, as can prescription drugs such as ospemifene. ‘The longer the gap without oestrogen, the longer it takes to reverse symptoms,’ warns Dr Briggs.

Vaginal moisturisers are useful too, but stick to brands such as Sylk and Yes as they do not contain perfumes or additives found in soaps, bubble bath or talcum powders that irritate sensitive skin.

For lichen sclerosus, steroid creams can reduce the inflammation causing the discomfort in about 95 per cent of cases.

But your GP should also refer you to a gynaecologist or dermatologist to rule out skin cancer, as the symptoms are similar.

WHY YOU SHOULDN’T IGNORE EXTREME PMS  

It’s a familiar feeling for millions of women – sudden, inexplicable despair that strikes around the same time every month. About 90 per cent of women suffer premenstrual syndrome mood changes or anxiety, and most manage symptoms with painkillers or lifestyle tweaks.

But for the estimated five to eight per cent with the most extreme form of the condition – called premenstrual dysphoric disorder (PMDD) – the symptoms can be utterly debilitating, with many experiencing suicidal thoughts and self-managing with alcohol.

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Many women suffer occasional discomfort during sex, but persistent pain or bleeding afterwards should always be checked out

WHAT CAUSES IT?

Again, a drop in the sex hormone oestrogen, coupled with the rise in levels of the hormone progesterone before a period.

This triggers a decline in levels of serotonin – a chemical neurotransmitter which helps to regulate mood.

Research shows a minority of women are extremely sensitive to these hormonal fluctuations, probably due to genetic susceptibility.

WHAT CAN I DO?

Getting the right diagnosis is key, yet PMDD is poorly understood by many doctors.

If you believe you suffer with it, visit a helpful website – such as the one run by charity Mind – and print off some of its PMDD information pages. Show them to your GP to help them understand your symptoms.

One effective treatment, according to Dr Briggs, is suppressing ovulation, using the combined contraceptive pill. This controls fluctuating hormones. Other women may need antidepressants such as fluoxetine or sertraline, but only for the last two weeks of each menstrual cycle rather than every day.

A trial of a drug called sepranolone, which inhibits chemicals in the brain involved with PMDD, found it reduced symptoms by 80 per cent in a group of 120 women. Now a larger trial, involving 250 women, has started.

Over 40 and ‘leaking’? It’s more common than hay fever 

Incontinence, or ‘leakage’, affects nearly half of all mothers, and in women over the age of 40 is more common than hay fever. And although it’s often linked to advancing years, it happens in younger women too.

There are two types – stress and urge incontinence – though some people suffer both at the same time. Stress incontinence is triggered by coughing, sneezing or exercise, whereas urge incontinence usually happens without an obvious trigger.

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Incontinence affects nearly half of all mothers

WHAT CAUSES IT?

Stress incontinence stems from weakness in the pelvic-floor muscles, usually from pregnancy, being overweight or chronic coughing. Laughing, coughing or exercise puts extra strain on these muscles, causing urine to leak.

It’s also more common after the menopause, as the lack of oestrogen in the body further weakens these muscles. Urge incontinence is related to an overactive bladder – the muscles contract unexpectedly, so you feel a sudden sense of needing to go.

WHAT CAN I DO?

‘Women can buy Tena lady pads in the supermarket, but that’s just surviving with the problem and not dealing with it,’ says gynaecological cancer nurse Tracie Miles, from The Eve Appeal charity, who has suffered with the problem herself. Seeing your GP is the first step. Different kinds of incontinence require different treatments.’

Simple exercises to strengthen the pelvic floor can tackle stress incontinence, such as tensing the muscles several times each day for ten seconds, squeezing as if to stop yourself urinating.

Severe cases may need surgery to correct any prolapse.

Urge incontinence responds well to medication but a type of training called a ‘bladder drill’ is also effective, which involves gradually increasing the amount of time between urinating.

WHEN PAINFUL SEX CAN BE A SIGN OF CANCER

Many women suffer occasional discomfort during sex, but persistent pain or bleeding afterwards should always be checked out.

Vaginal pain, or dyspareunia, is divided into two categories. Either it is ‘superficial’ and felt in the vagina and vulva, or it is ‘deep dyspareunia’, which is felt in the pelvis or abdomen.

After the menopause, superficial discomfort during sex is incredibly common, as reduced levels of oestrogen and progesterone make the sensitive tissues dry and sore. In roughly two-thirds of older women, this can result in a small amount of blood after sex – which is usually nothing to worry about.

WHAT CAUSES IT?

Common causes of bleeding after sex include a benign growth in the cervix, called a polyp, as well as side effects of the contraceptive pill. Sexually transmitted infections such as chlamydia or gonorrhoea – which are increasingly common in women over 50 – can also cause bleeding.

In worst-case scenarios, bleeding after sex could be an indication of cell changes in the cervix, which may signal cervical cancer. On average, nine new cervical-cancer cases are diagnosed every day in the UK – more than 3,200 a year – and the average age of diagnosis is 50. But treatment is very effective if it is caught early.

Sometimes painful sex is due to vaginismus – involuntarily tightening of the vaginal muscles when penetration is attempted.

If the deep pain exists without bleeding, it could be endometriosis – a common condition in which womb tissue grows outside the womb, or non-cancerous growths called fibroids. Most worryingly, it could signal ovarian cancer.

WHAT CAN I DO?

Your GP can take swabs from inside the vagina, or a urine test, to rule out sexually transmitted infections. A smear would also be used to check for changes which could lead to cervical cancer.

Depending on the results, this may be followed up with an internal ultrasound, in which a small probe is inserted into the vagina.

A blood test may be carried out to check for signs of ovarian cancer. It measures levels of a protein called CA125, which may be present if there is a tumour.

If the pain is superficial, the GP can prescribe hormone creams, emollients and lubricants.

And if the problem is vaginismus, the tight muscles can be retrained with vaginal dilators or you may be referred to a psychosexual counsellor to ease physical tension.

FEMININE WASHES CAN DO MORE HARM THAN GOOD

Millions of women miss out on cancer cure 

One in four women skip their routine smear tests, meaning thousands develop cervical cancer each year when it could have been prevented.

The test, which involves taking a swab from the cervix (the neck of the womb), looks for signs of the human papillomavirus (HPV), which is responsible for most cases of cervical cancer.

If detected, doctors carry out further tests to check for any abnormal changes to cells, which could indicate early signs of cancer. Treatment is given early, which in the majority of cases cures the disease.

But uptake of these vital tests is now at its lowest rate in two decades, with four million women missing out on at least one test.

There are multiple reasons for this, including embarrassment, but also disabilities and a history of sexual trauma.

Also, a small number of women have a condition that affects the position of their cervix, which makes undergoing the procedure uncomfortable.

But for the majority of women, smear tests – which should be arranged every three years for 25-49-year-olds and every five years for 50-65-year-olds – are painless.

Imogen Pinnell, from the charity Jo’s Cervical Cancer Trust, said: ‘We know that smear tests can be embarrassing or nerve-racking. But, ultimately, they can prevent 75 per cent of cervical cancers from even beginning.

‘It is important to talk about barriers to screening, which support can often be offered for.’

We all know about ‘friendly’ gut bacteria by now, but a wide range of bacteria live all over our skin, including inside the vagina, forming a balanced ecosystem.

This bacterial cocktail can cause a slight, subtle smell, which changes throughout the menstrual cycle. Lots of women think this is a sign of poor hygiene, a myth perpetuated by marketing companies to sell dubious and potentially harmful washes and deodorants.

The vagina is, in fact, one of the cleanest organs in the body – as its healthy bacteria kill nasty ones.

A slight smell is normal, but it may get stronger at certain times in the menstrual cycle. If it becomes especially pungent (often described as fishy, with a watery discharge), it could be a common problem called bacterial vaginosis.

WHAT CAUSES IT?

Bacterial vaginosis, which affects one in three women, develops when the natural balance of bacteria in the vagina becomes disturbed, causing a growth in an organism called gardnerella.

Unlike thrush, a fungal infection often triggered by sex or a weakened immune system, bacterial vaginosis usually comes from over-cleaning or using scented products. Such products alter the delicate pH balance of the vagina – a measure of how acidic it is – which can then disrupt its bacterial ‘formula’.

Unlike normal discharge – a thick mucus that keeps the vagina clean and moist – bacterial vaginosis makes it very runny and clear, although some women won’t notice a change in texture at all.

WHAT CAN I DO?

Treatment usually involves prescribed antibiotic tablets, gels or creams which restore the bacterial balance within a week.

Further problems are rare but gynaecologists warn that there’s a risk of early delivery if you’re pregnant and leave it untreated.

As for thrush, over-the-counter anti-fungal creams, tablets and pessaries clear it up quickly.

THERE IS HOPE AFTER HAIR LOSS  

About half of women over 65 have inherited pattern baldness, otherwise known as androgenetic alopecia. But it can also be triggered by a drop in oestrogen levels after the menopause, which damages the hair follicles. Tory MP Nadine Dorries said that her gradual hair loss after the menopause made her ‘cry every morning’.

WHAT CAUSES IT?

Aside from the menopause, it could be deficiencies in nutrients, such as zinc and iron, or even thyroid problems. And roughly two per cent of the population has alopecia areata, where the hair follicles are damaged by a malfunctioning immune system, causing patches of hair loss or total baldness.

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About half of women over 65 have inherited pattern baldness, but hair loss can also  be triggered by a drop in oestrogen levels after the menopause

WHAT CAN I DO?

Firstly, blood tests by a GP can spot any underlying hormonal, thyroid or vitamin deficiencies.

If it’s an iron deficiency, for example, it can be treated with supplements, while thyroid problems respond well to treatment with the hormone thyroxine.

Other treatments include steroid creams, steroid scalp injections and a lotion, or foam, called Minoxidil. But these are not usually available on the NHS and must be accessed privately.

LOOK OUT FOR CHANGES TO YOUR ‘NORMAL’  

Most women have some vaginal discharge, which is typically clearer and more watery before ovulation but thicker and stickier in the second half of the menstrual cycle. But when it becomes uncharacteristically thick, frothy or is green in colour, it could be a problem.

WHAT CAUSES IT?

It could be a yeast infection, such as thrush, but other causes include trichomoniasis, a bacterial infection that makes discharge green and watery, failure to remove a tampon or sexually transmitted gonorrhoea (which generates a thick yellow discharge).

When coupled with other symptoms, such as blood traces or pains, it could be signs of cervical or endometrial cancer.

WHAT CAN I DO?

Antibiotics or antifungal medication should take care of thrush, bacterial infections or a sexually transmitted infection.

Thrush treatment is available over the counter, while the others need a prescription from a GP.

But remember, most discharge is completely harmless and normal. You should be concerned only if it’s a significant change in what is usual for you.

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