Sex, Sleep or Scrabble

by Hammond, Phil

  The trick with smears is to give some thought about how you’d like to be treated and let the nurse know. Do you like the cosy chat or do you prefer clinical silence? Would you like a chaperone? Do you prefer a warm or freezing speculum? If you want a GP to do a smear, don’t slip it in at the end of the ten minutes. You’ll be told to book a whole consultation. Not to be confused with a consultation for your hole.

  Is cervical cancer a sexually transmitted infection?

  No, but it can be triggered by one. Infection with certain types of human papilloma virus (HPV) can cause changes in the cervix which can one day lead to cancer. So there are various ways of reducing your risk of cervical cancer. One is to not have many partners. Another is to always use condoms no matter how many partners you have. Another is not to miss any cervical smears. Another is not to smoke, which seems to make it more likely for the damage caused by HPV to progress to cancer. And the newest way is to have a course of an HPV vaccine, which seems very effective at stopping the types of virus most commonly associated with cancer.

  Currently, girls can get the HPV vaccine Cervarix free in the UK in a school-based vaccination programme (it’s most effective if given before you’ve ever had sex). Outside of the programme you may have to pay, especially if you want the Gardasil vaccine which protects against both cancer and genital warts.

  Why does my bra ride up my back?

  Either because it’s too big, it’s come undone or you forgot to do it up in the first place. If it keeps happening, you either need a new bra or a visit to the memory clinic.

  A surprising number of women wear bras that don’t fit. And there are so many on the market, it’s not easy to get the cups, shoulder straps, body straps, wires, under-wires, cross over wires, hooks and fastenings all in the right place … and look attractive. If yours wrinkles, squashes together, sticks up, digs in, bulges out, rides up, looks ridiculous or gives you back pain, treat yourself to a proper fitting with a bra specialist. I’m told it’s a life-changing event for many women.

  Should I wear crotchless pants to the doctors?

  No thanks. They can shave a minute or so off a smear but they do send out the wrong message. As a naïve student (ginger hair, science A levels, not many girlfriends), I encountered my first pair of lady-gap knickers and assumed the owner must have snagged them alighting from her bicycle. Some male GPs claim to be thrown off-kilter by ‘inappropriate underwear’ but it’s sometimes hard to judge what’s acceptable. Will only pristine white cotton ones do? In an ideal world, any underwear exposed to strangers should pass the Daz doorstep challenge but sod’s law of appendicitis is that when it flares up, you’re always sporting pants that, in Jo Brand’s immortal words, ‘should have been buried at the bottom of the garden with a stake through them.’

  After the menopause, do you just have to pad up and shut up?

  No. But I’d hate to be a woman. Birth, babies, periods, work-life guilt, caring, cleaning, more periods with heavier bleeding, hot flushes, even hotter flushes and then finally, mercifully, the menopause. But can you relax? Can you buggery. Vaginal dryness and soreness, painful sex, leakage of urine and recurrent wee infections that don’t respond to antibiotics. It doesn’t happen to every woman but when it does, far too many suffer in silence.

  So what’s going on here? Women (and men) have oestrogen receptors all over their bodies and after the menopause, the lack of oestrogen is felt everywhere. Most women are aware of the hot sweats, emotional changes and longer term risks of osteoporosis, but symptoms down there are harder to talk about. Without oestrogen, the skin and support tissues of the vulval lips and vagina become thin and less elastic. This makes them more easily damaged, especially during sex if lubrication is poor. Even the everyday friction of your vulva rubbing against underwear can cause discomfort. And don’t even try getting on a bike.

  The oestrogen lack also changes the pH of the vaginal secretions, suppressing normal levels of good bacteria (e.g. lactobacilli) and leading to a watery, discoloured, slightly smelly discharge that can cause burning and irritation. Unsurprisingly, some women think they must have a sexually transmitted infection.

  Lack of oestrogen also makes your pelvic floor sag, and many women get some prolapse as the womb drops down against a weakened vaginal wall (usually at the front). The hood that protects the clitoris can shrink, which can leave the clitoris sore, exposed and very difficult to talk about. And then there are the urinary tract symptoms, ranging from incontinence to an overactive bladder and recurrent symptoms of urinary tract infections.

  Talk it through with a health professional who’s likely to understand (say, a mid-fifties nurse. Don’t see many of them). Soap tends to make skin dry, which is bad news for an already dry vagina, so switching to aqueous cream can make a difference. As for lubricants, the best well-known (KY Jelly) is a lot messier than Liquid Silk or Replens MD (available on prescription or over the counter).

  Local oestrogen therapy can make a huge difference to vaginal dryness, soreness and urinary symptoms. It comes in the form of daily tablets, pessaries and creams, or a vaginal silica ring that can be inserted for three months. The good news is that the dose of oestrogen is low and the risk of side effects associated with HRT is much smaller. Pelvic-floor exercises are always worth doing, and there are even pelvic-floor physiotherapists who know all the tricks and tools to strengthen things up. Occasionally, surgery is needed for prolapse or stress incontinence (the kind that makes you leak when you cough or jump), but it’s much less invasive than it used to be. For further information, see www.menopausematters.co.uk

  INTERESTING FACT: After the menopause, women often have lower oestrogen levels than men.

  Should I squeeze before I sneeze?

  If you’ve got time, although sneezes can catch you unawares. There’s loads that can be done for an unpredictable bladder, whatever the cause, and I find the nurse knows far more about it than any GP. One of ours gets women and their partners to tighten the anus and work the pelvic floor as if in a lift. You start in the basement and work your way up to the penthouse suite, and back down again. Incontinence needs a friendly ear and a correct diagnosis. Once you’ve got that, treatment quickly follows.

  A teabag is good for vulval pain, but can I use it for tea first?

  You can, but you need to let it cool off first. Teabags, particularly Indian or Earl Grey (for the posher vulva), contain tannic acid which is a local anaesthetic and can sooth the lower lips. You can either put teabags in the bath or apply a cold damp bag directly to the sore area.

  Just as important is to get a correct diagnosis for your vulval pain. Genital herpes, especially the first attack, can be bloody sore and it can be painful or impossible to pass urine. You need more than teabags, you need a high dose of aciclovir (800mg three times a day), as soon as possible. If you catch it early, the worst may be over in just two days of treatment If you want an accurate diagnosis and a free prescription, a sexual health clinic is the place to be. (See also Is herpes worth the hype?).

  A lot of people never get recurrences of herpes or get them so mildly they don’t realise. But if you’re one of the unlucky few who get severe recurrences, you can either have regular suppression treatment or learn to spot an attack early and nip it in the bud. The virus lives quite harmlessly in the spinal nerve roots, only causing pain when it travels down the end of a nerve. The commonest warning shot is a tingling sensation – could be in the lower buttocks, down the back of the legs to the knee, or round the backside. That’s the time to take the tablets. Get them in time and you won’t need to waste a teabag.

  Other causes of a painful vulva are poorly understood so we give them a silly name. ‘Vulval vestibulitis syndrome’ is sudden pain, often right at the opening for no apparent reason, more common in young women. ‘Vulvodynia’ is more of an aching and itching, often worse at night, and more common in older women. The vulva looks normal but the pain isn’t. And then there’s cancer of the vulva which, like cancer of the penis, is ra
re but not something you’d want to sit on. Get it checked out.

  Things to do with your vulva:

  • Love it. It will get better in time.

  • Use unperfumed soap, such as Simple.

  • Wash your pants in ‘sensitive’ detergent.

  • Put two handfuls of salt in your bathwater.

  • Pee in the bath (it often helps the pain).

  • Other things that some women find helpful include talking, listening, ice, aloe vera gel, aqueous cream, vitamin E oil (squeezed out from a capsule) and oatmeal (Aveeno) baths.

  • Your GP can offer guidance on anaesthetic cream (which can safely enable you to have sex, if you want to try), prescription drugs for pain or referral to a vulval clinic.

  • Contact the Vulval Pain Society www.vulvalpainsociety.org

  Things not to do with your vulva:

  • Give up.

  • Get bubble bath, shower gel or shampoo near it.

  • Use any deodorant down there, intimate or otherwise.

  • Douche, shower or squirt anything into your vagina. Like your ears, it cleans itself perfectly naturally (well, not quite like your ears but the point is, let it be).

  • Get confused surfing – Americans say ‘vulvar’, not ‘vulval’, but they have some good sites too (e.g. www.vulvarhealth.org).

  • Punish it.

  How do you put yoghurt into your vagina without getting it all over the settee?

  Putting live yoghurt over your vulva and into your vagina can relieve the symptoms of thrush, but may not make it go away any faster. If you want to have a go, the vulva is easy enough to cover but the vagina can be a bit awkward. A good way of getting it up high is to put a tampon in an applicator and leave a space at the top for yoghurt. Then pop it in the normal way, remembering to take it out again in an hour or so. If that doesn’t work, there are plenty of thrush remedies available over the counter. You could just do it for the taste of yoghurt, but be wary of the whole-fruit pieces.

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  Should I turn my belly button inside out to clean it?

  No, that will only make it sore. If it’s already sore or discharging, wash it gently with salty water and tenderly dab it dry. If the discharge doesn’t go or turns yellow, show a nurse. If a baby comes out of it, you’re dreaming or on mushrooms.

  Should I pop piles back in with the end of my toothbrush?

  Not with the brushing end. Haemorrhoids, like singers, usually come in three degrees. First-degree piles stay in the anus and generally don’t trouble you, second-degree piles pop down when you have a poo but then pop back up again. Third-degree piles also pop down with straining but don’t go back without a little help. Don’t use anything as hard as a brush handle, just gently push them up with your finger while relaxing the sphincter. Now wash your hands. If you’re really unlucky, you can get a fourth-degree pile that hangs around permanently. But she was never really part of the group and Dianna Ross won’t talk about her.

  Piles are derived from the Latin pila or ball, and strictly could apply to any roughly spherical swelling peeping through the anal verge (e.g. a misplaced walnut or a lost bearing). Haemorrhoid, on the other hand, is Greek for blood flow. Don’t assume that bleeding coming from your rectum is due to piles. It probably is, but it’s worth getting a medical opinion.

  Piles are not varicose veins, but swollen, sponge pads. A healthy anus has three spongy pads (at 4, 7 and 11 o’clock around the margin if you’re lying on your back with your legs in the air and a well-placed vanity mirror). These are like lips at the other end of your gut, and they act as an extra seal to keep the backdoor shut until the brain commands it to open. A pile is simply one of these soft pads that has slipped down (often through over-straining to pass a few hard pellets) and, as it slips, its blood vessels are compressed, making it swell up. This can result in an itching, aching, bleeding, tender lump and even skid marks if the seal goes. If the piles are up inside you, you may get painless, bright red drips of blood into the toilet, streaks on the paper or a coating of the stool (but not mixed in with it, which suggests bleeding higher up). External piles can bleed too, if a clot breaks through the skin. This is rarer and usually noticed as a stain on the pants.

  Most of us get piles at some stage, as a punishment for evolving to walk upright (so things have a tendency to slip down). Piles can run in families and pregnancy, age, heavy lifting, heavy body, diarrhoea and constipation increase the risk. However, cold stone walls and hot radiators don’t make piles more likely, just more likely that you’ll feel them. They can go away on their own, particularly if you avoid the urge to scratch. The itchiness is down to a little lower bowel mucus leaking out and irritating the skin. Washing gently with warm, salty water, dab drying with cotton wool balls and a light smearing of petroleum jelly may be all that’s needed to keep them in check.

  Soft bog paper helps, or a bidet if you’re posh, as do baggy pants, plenty of fibre and fluids and easy on the after strain. Piles can trick the body into thinking there’s more to come when there isn’t, so a swift drop off with no loitering is best. Laxatives and paracetamol are a good combination, and there are lots of soothing ointments and gels available over the counter. Some have unfortunate names like Anusol which – depending on how it’s pronounced – can rather give the game away when shouted across a crowded dispensary.

  Persistent third-or fourth-degree piles might need a little extra help. Most respond to putting a rubber band over the base until it falls off. It leaves a scar and it can cause soreness for forty-eight hours and bleeding, particularly if you’re on blood-thinning drugs. But it sorts out the problem in eight out of ten cats. Old-fashioned haemorrhoidectomy is generally reserved for the really, really, really severe cases. Your legs are placed in the air and the piles are grasped with clamps and cut out with any accompanying skin tags all the way to the neck (of the pile, not you). On the upside, you do get a general anaesthetic for your trouble; on the downside, you need to be in hospital until your bowels have started working again which, according to my surgical textbook, may cause ‘a certain amount of pain.’ This is a euphemism for ‘shitting a hedgehog backwards.’ However, you get painkillers, laxatives and, if there isn’t a staffing crisis, twice-daily baths to soothe the operation site and keep it clean. The wound may take four to six weeks to heal completely, during which time some discharge is normal. Newer methods, particularly removing the pile and stapling the skin edges back together, seem to have a quicker recover time.

  Do piles strangle themselves?

  Occasionally. Strangulated piles occur not for erotic pleasure but when a fourth-degree pile swells up, becomes very inflamed and then clots off. This can be so painful as to need urgent surgery. External haemorrhoids eventually shrink down to skin tags that make wiping a bit of a challenge, and may be excised.

  Can I take my piles home with me?

  You own your body parts, at least until you die, and if you ask nicely beforehand, you may be allowed to take them home for a formal burial. Or you may just get a look of bewilderment and a visit from the duty psychiatrist.

  Can you catch threadworms by putting sticky tape over your anus?

  You can catch the threadworms you already have, as they pop out of your anus at night and lay thousands of itchy eggs around the rim. You then scratch your arse, get the eggs under your nails and (later) put your fingers in your mouth, allowing the cycle of infection to repeat. Ingenious, really. As Dr Dog puts it: ‘Never scratch your bum and suck your thumb.’

  Threadworms are white, just over a centimetre long and everyone gets them. You can get treatment over the counter (merbendazole), and are supposed to treat the whole family three times, a month apart, to cover any un-hatched eggs, as well as meticulous hand-washing, nail-clipping and separate bum towels. Or you can leave them be and hope they die out in six weeks.

  What’s the best cure for anal itch?

  Don’t scratch it. Wear loose pants and wash with water (o
nly) after poos, dab dry, rub in a bit of aqueous cream but avoid soaps, disinfectants and deodorants. Some get relief from a cotton-wool ball dusted with baby powder and placed against the anus. The traditional remedy is to dab the dark star with the inside of a banana skin, but I’ve no idea who started that. King Kong, perhaps.

  My GP said I could relieve my anal pain by sitting on a tennis ball. Shall I sue?

  If he said it with a straight face, he probably thinks you’ve got proctalgia fugax, a ridiculous name masking the fact that we don’t know why you’re cramping up down there. The best guess is that it’s a spasm of your rectal and pelvic-floor muscles, and if you’re unlucky (and a man), you may get it after sex or even wake up at night with both the pain and an erection. It’s hard to know what to do first in these situations. One tip that works for some is to put pressure on your perineum (the area between anus and genitals) by sitting on the edge of a bath or on a tennis ball. Don’t try both – you’re liable to slip off.

  Some find a hot bath does the trick, others head for the ice. Drugs generally don’t work because most cramps are over in the time it takes you to find them. If you get anal pain through a whole episode of Eastenders, it might be worth considering a prescribed drug to relax your smooth muscle. GTN spray (used for angina) or a salbutamol puffer (used for asthma), sometimes work if taken at the start of the pain. Failing that, it’s two paracetamol and a mug of Horlicks (with or without the tennis ball). But you definitely don’t need a lawyer.