Male sexual problems

Page last reviewed: 10/06/2014

Next review due: 09/06/2016

Source: NHS Choices, UK

Introduction 

Loss of libido (sex drive) is a common problem affecting up to one in five men – and even more women – at some point in their life.

It's often linked to professional and personal stress, or important life-changing events such as pregnancy, childbirth or breastfeeding.

However, an unexpected loss of libido – especially when it lasts for a long time or keeps returning – can also indicate an underlying personal, medical or lifestyle problem, which can be upsetting to both partners in a relationship.

If you're concerned about your libido, especially if your diminished sex drive distresses you or affects your relationship, make an appointment to see your GP to discuss any underlying causes and possible medical or psychological treatments.

Doctors at your nearest family planning clinic, Integrated Sexual Health clinic, or Contraceptive and Sexual Health (CASH) clinic may also be able to help.

In the meantime, you may find the following information useful. It explains some of the most common reasons for loss of libido.

Relationship problems

The first thing you should consider is whether you're happy in your relationship. Do you have any doubts or worries that may be the real reason for your loss of sexual desire?

If you've been in a relationship for a long time, you may have become overfamiliar with your partner and feel a degree of erotic dissatisfaction. This is quite common and can have a negative effect on your sex drive.

Relationship problems are among the most common causes of loss of libido. For help and advice, you may find it useful to contact the relationship support charity Relate.

Another thing to consider is whether the problem is a performance issue that makes sex difficult or unfulfilling. For example, many men experience ejaculation problems or erectile dysfunction, and women can experience painful sex or vaginismus (when the muscles around the vagina tighten involuntarily before penetration). See your GP if these problems are an issue, as they're often treatable.

Your GP may feel you will benefit from psychosexual counselling. This is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your loss of libido. Read let's talk about sex for more information about this.

Stress, anxiety and exhaustion

Stress, anxiety and exhaustion can be all-consuming and have a major impact on your happiness. If you feel you're constantly tired, stressed or anxious, you may need to make some lifestyle changes or speak to your GP for advice.

For more information and advice, you may find some of the following pages useful:

• Why am I tired all the time?
• Why do I feel anxious and panicky?
• Self-help tips to fight fatigue
• Beating stress at work
• Relaxation tips to relieve stress
• 10 stress busters

Depression

Depression is very different from simply feeling unhappy, miserable or fed up for a short while. It's a serious illness where you may have feelings of extreme sadness that can last for a long time. These feelings are severe enough to interfere with your daily life, including your sex life.

You're probably depressed if you're feeling low or hopeless, or you've lost interest or pleasure in doing things you used to enjoy. In this case it's really important to see your GP. They may feel you'll benefit from antidepressants.

However, low sex drive can also be a side effect of many antidepressants. Speak to your GP if you're already taking antidepressants and think they may be causing your problems, as you may be able to switch to a different medication.

Drugs and alcohol

Drinking excess amounts of alcohol can reduce your sex drive, so it's a good idea to moderate your intake to no more than three to four units a day if you're a man, and no more than two to three units a day if you're a woman.

Read more about alcohol misuse and find out how to get support for a drinking problem.

Drug misuse is also linked to a loss of sex drive. Read more about drugs for information and advice.

Getting older

Many people lose some interest in sex as they get older, mainly as a result of falling levels of sex hormones, age-related health problems, or the side effects of medication.

Older men especially can develop low testosterone levels, which can cause fatigue, depression and a reduced sex drive.

Speak to your GP if you're concerned about this. They may carry out a blood test to check your testosterone level and can tell you about treatments if your level is low.

As women start to approach the menopause, levels of the female hormone oestrogen begin to fall, which can affect libido. Women can also suffer from low testosterone levels, especially after a hysterectomy. Testosterone is another hormone that can affect sex drive.

Speak to your GP if you're concerned the menopause may be having an effect on your libido. They may be able to offer you a trial of hormone replacement therapy (HRT) if it's suitable for you.

Hormonal problems

Less commonly, low libido may be caused by an underactive thyroid. This is where your thyroid gland (located in the neck) doesn't produce enough hormones. Common signs of an underactive thyroid are tiredness, weight gain and feeling depressed.

An underactive thyroid is easily treated by taking hormone tablets to replace the hormones your thyroid isn't making. Learn more about treating underactive thyroid.

A hormonal problem called hyperprolactinaemia can also have a negative effect on your sex drive. This is where you have a raised level of a substance called prolactin in your blood.

Contraception

Some women have reported a decreased sex drive while using some types of hormonal contraception, such as:

• combined contraception, including the combined pill, vaginal ring, or contraceptive patch
• the progestogen-only pill
• the contraceptive implant
• the Depo-Provera injection

However, side effects of these contraceptives tend to improve within a few months and they're generally well tolerated.

Speak to your GP or local contraceptive (or family planning) clinic if you're worried your contraception is causing a loss of libido. They may suggest trying an alternative method.

Read more about choosing a method of contraception.

Other medical conditions

Long-term (chronic) medical conditions such as cardiovascular disease, diabetes and obesity can also have a negative effect on your libido.

Medication

Certain medications can sometimes reduce libido, such as:

• medication for high blood pressure, including diuretics
• medications for depression, including SSRI antidepressants
• medications for seizures (fits)
• medications commonly used to treat psychosis (a mental condition where a person can't distinguish between reality and their imagination), such as haloperidol, as well as many other conditions
• medicines such as cimetidine, finasteride and cyproterone, which block the effects or reduce the production of testosterone

See your GP if you're worried that medication you're taking is responsible for your reduced sex drive. They can review your medication and switch your prescription to something less likely to affect your libido if necessary.

Page last reviewed: 23/01/2015

Next review due: 23/01/2017

Source: NHS Choices, UK

The male midlife crisis is often made fun of, but for many men it is a distressing experience.

Introduction 

Erectile dysfunction (ED), also known as impotence, is the inability to get and maintain an erection.

Erectile dysfunction is a very common condition, particularly in older men. It is estimated that half of all men between the ages of 40 and 70 will have it to some degree.

When to see your GP

See your GP if you have erectile dysfunction for more than a few weeks. They will assess your general state of health because the condition can be the first sign of more serious health conditions, such as heart disease (when the heart’s blood supply is blocked or interrupted).

Why does erectile dysfunction happen?

Erectile dysfunction can have a range of causes, both physical and psychological. Physical causes include:

• narrowing of the blood vessels going to the penis – commonly associated with high blood pressure (hypertension), high cholesterol or diabetes
• hormonal problems
• surgery or injury

Psychological causes of ED include:

• anxiety 
• depression 
• relationship problems

Sometimes erectile dysfunction only occurs in certain situations. For example, you may be able to get an erection during masturbation, or you may find that you sometimes wake up with an erection but you are unable to get an erection with your sexual partner.

If this is the case, it is likely the underlying cause of erectile dysfunction is psychological (stress related). If you are unable to get an erection under any circumstances, it is likely that the underlying cause is physical.

Erectile dysfunction can also be a side-effect of using certain medicines.

Read more about the causes of erectile dysfunction.

Diagnosis

Although you may be embarrassed, it's important to get a diagnosis so that the cause can be identified.

Your GP can usually diagnose erectile dysfunction. This will involve answering questions about your symptoms, as well as a physical examination and some simple tests.

Read more about diagnosing erectile dysfunction.

How is erectile dysfunction treated?

Erectile dysfunction is primarily treated by tackling the cause of the problem, whether this is physical or psychological.

The narrowing of the arteries (called atherosclerosis) is one of the most common causes of ED. In these cases your GP may suggest lifestyle changes, such as losing weight, to try to reduce your risk of cardiovascular disease. This may help to relieve your symptoms as well as improving your general health.

You may also be given medication to treat atherosclerosis, such as cholesterol-lowering statins and drugs to reduce your blood pressure.

A number of treatments have been successful in the treatment of erectile dysfunction. Medication, such as sildenafil (sold as Viagra), can be used to manage it in at least two-thirds of cases. Vacuum pumps that encourage blood to flow to the penis and cause an erection are also successful in 90% of cases.

Psychological treatments include cognitive behavioural therapy (CBT) and sex therapy.

Overall, treatments for erectile dysfunction have improved significantly in recent years. Most men are eventually able to have sex again.

Read more about treating erectile dysfunction.

Next review due: 23/09/2016

Source: NHS Choices, UK

Introduction 

Ejaculation problems, such as premature ejaculation, are common sexual problems in men.

The three main problems are:

• premature ejaculation 
• delayed ejaculation 
• retrograde ejaculation 

These are described in more detail below.

Premature ejaculation

Premature ejaculation is the most common ejaculation problem. It is where the male ejaculates too quickly during sexual intercourse.

Many men are unsure about how long ‘normal’ sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between a man putting his penis into his partner’s vagina and ejaculation was around five-and-a-half minutes.

However, it's up to the individual and his partner to decide whether or not they're happy with the time it takes for him to ejaculate. There is no definition of how long intercourse should last.

Occasional episodes of premature ejaculation are common and not a cause for concern. However, if you're finding that around half of your attempts to have intercourse result in premature ejaculation, it might help to get treatment.

Most men with this problem won't have always had it – they'll have previously ejaculated normally. This may be referred to as 'secondary' premature ejaculation.

It's less common for the man to have always experienced premature ejaculation (since becoming sexually active) – this is known as 'primary' or lifelong premature ejaculation. It affects around one in 50 men in England. In most cases of lifelong premature ejaculation:

• there is an inability to delay ejaculation during sex every time or most times
• the condition causes feelings of shame or frustration and impacts on quality of life, causing the man to avoid sexual intimacy

Delayed ejaculation

Delayed ejaculation (male orgasmic disorder) is classed as either:

• experiencing a significant delay before ejaculation is possible
• being unable to ejaculate at all even though the male wants to and his erection is normal

There is no set definition to describe ‘how long is too long’, but a persistent (and unwanted) delay of ejaculation that lasts for 30 to 60 minutes may suggest delayed ejaculation.

Alternatively, if you are unable to achieve ejaculation at least half the times you have sex, you may have delayed ejaculation.

As with premature ejaculation, delayed ejaculation can be either acquired or lifelong. Lifelong delayed ejaculation is less common and affects an estimated one in 1,000 men.

Delayed ejaculation can occur in all sexual situations, or just in certain situations – for example, you may be able to ejaculate normally when masturbating, but not during sex. When delayed ejaculation only happens in certain situations, there's usually a psychological cause.

Retrograde ejaculation

Retrograde ejaculation is a rarer type of ejaculation problem. It happens when sperm travels backwards and enters the bladder instead of coming out of the end of the urethra (the tube through which urine passes).

The main symptoms of retrograde ejaculation include:

• producing no semen, or only a small amount, during ejaculation
• producing cloudy urine (because of the semen in it) when you first go to the toilet after having sex

Men with retrograde ejaculation still experience the feeling of an orgasm and the condition does not pose a danger to health. However, it can affect the ability to father a child (read about infertility).

Treating ejaculation problems

Premature ejaculation can be treated with medication, such as the selective serotonin reuptake inhibitors (SSRIs) type of antidepressant, which can help delay ejaculating.

Couples therapy, a form of counselling, can be useful in coming up with techniques for partners to practice to help delay ejaculation.

Recommended treatments for delayed ejaculation depend on the underlying cause. If it is thought to be a side effect of medication, switching to an alternative medication will help. However, if the cause is thought to be psychological, counselling may be recommended.

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not affect their health. In some cases, medication may be used to help restore normal ejaculation.

However, if you want to have children, you may need fertility treatment to extract a sample of sperm.

Read more about treating ejaculation problems.

What causes ejaculation problems?

Ejaculation problems are complex and can be caused by a number of things, including:

• stress
• relationship problems
• anxiety – such as a man being anxious that he will lose his erection (erectile dysfunction), causing him to ‘rush’ the intercourse
• previous traumatic sexual experiences
• depression
• some medical conditions or medicines – for example, diabetes can cause delayed ejaculation

Some researchers think certain men are more prone to premature ejaculation because of their biological make-up, such as having an unusually sensitive penis.

Retrograde ejaculation is caused by damage to nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder). This damage can often occur as a complication of prostate or bladder surgery.

Read more about the causes of ejaculation problems.

Who is affected

Premature ejaculation is the most common type of ejaculation problem.

A number of surveys have found around one in three men reported being affected by premature ejaculation. The true figure is probably much higher as many men are reluctant to admit they have this problem.

While less common, delayed ejaculation is probably more of a problem then most people realise. One study found around one in 20 people had problems achieving an orgasm over the course of a month during the past year.

Although retrograde ejaculation is rare, it can be a common complication of some types of surgery, such as prostate surgery, or in men with certain health conditions that can damage the nerves, such as diabetes or multiple sclerosis.

The male midlife crisis

The male midlife crisis is something people joke about, but it can be distressing for those going through it

Page last reviewed: 15/07/2014

Next review due: 15/07/2016

 Source: NHS Choices, UK

Treating erectile dysfunction 

If you have erectile dysfunction (ED), treatment will depend on what's causing it.

Read on to learn about the different treatments you may be offered.

You can also read a summary of the pros and cons of these treatment options, allowing you to compare your treatment options.

Treating underlying conditions

If your erectile dysfunction is caused by an underlying health condition, such as heart disease or diabetes, that condition may need to be treated first. In some cases, treating the underlying cause may also resolve the problem.

If you are taking medication that can cause erectile dysfunction, there may be an alternative. It is important never to stop taking a prescribed medication unless you are advised to do so by your GP or another qualified healthcare professional responsible for your care.

Lifestyle changes

Erectile dysfunction can often be improved by making changes to your lifestyle, such as:

• losing weight if you are overweight   
• giving up smoking
• cutting back your alcohol consumption 
• not taking illegal drugs 
• exercising regularly 
• reducing stress 

As well as helping to improve your erectile dysfunction, these changes can also improve your general health and may help to reduce your risk of cardiovascular disease (conditions that affect your heart and blood vessels).

Read more about preventing cardiovascular disease.  

Phosphodiesterase-5 (PDE-5) inhibitors

Phosphodiesterase-5 (PDE-5) inhibitors are one of the most widely used and effective types of medication for treating erectile dysfunction. They work by temporarily increasing the blood flow to your penis.

In England, four PDE-5 inhibitors are available for treating erectile dysfunction. They are:

• sildenafil – sold under the brand name Viagra 
• tadalafil – sold under the brand name Cialis
• vardenafil – sold under the brand name Levitra
• avanafil - sold under the brand name Spedra

Sildenafil, vardenafil and avanafil work for about eight hours and they are designed to work 'on demand'. Tadalafil lasts for up to 36 hours and is more suitable if you require treatment for a longer period of time, for example, over a weekend.

Depending on the type of PDE-5 inhibitor you are taking and the dose, it should take about 30-60 minutes before it starts to work. With sildenafil, vardenafil and avanafil, you should be able to have sex from one to 10 hours after taking the medicine. After taking tadalafil, the effects will last for up to 36 hours.

It may take longer to notice the effects if the tablet is taken with food, so it's best to take it on an empty stomach. You can then eat after an hour without affecting the medicine.

Only take one tablet within a 24-hour period.

Your GP should explain the benefits of each medication and how it works. The choice may depend on:

• how often you are sexually active 
• whether you have tried any of the medications before

There have been many studies to test the effectiveness of these medications. In general, at least two-thirds of men report having improved erections after taking one of these medicines.

If you do not find that PDE-5 inhibitors are effective it may be because:

• you have not waited long enough after taking the dose
• you have waited too long after taking the dose
• the dose is not high enough
• you have not had enough sexual stimulation

These medications are triggered by sexual stimulation, so you also need to be aroused for it to work.

Warnings

PDE-5 inhibitors should be used with caution in men who have cardiovascular disease, such as coronary heart disease. However, sexual activity is also likely to be beneficial for your cardiovascular health. You should discuss the risks and benefits with your GP.

PDE-5 inhibitors should also be used with caution in men who have anatomical problems with their penis, such as Peyronie's disease (a condition that affects the tissue of the penis).

PDE-5 inhibitors should also be used with caution in men who:

• are at risk of priapism – a painful erection that lasts for several hours
• are also taking long lasting alpha-blockers – a medication used to treat a number of conditions, such as high blood pressure (hypertension)

Do not take PDE-5 inhibitors if you are also taking medicines or recreational drugs that contain nitrates. The combination of the two substances can have a dangerous effect on your heart.

Organic nitrates are often used to treat angina, and butyl nitrate is a recreational drug that is more commonly known as 'poppers'.

You are also warned not to take PDE-5 inhibitors if you:

• have been advised not to take part in sexual activity or in activities that widen your blood vessels 
• have low blood pressure (hypotension) 
• have recently had a stroke – a medical emergency that occurs when the blood supply to the brain is interrupted
• have unstable angina – an underlying heart condition that causes symptoms such as chest pain
• have had a heart attack – a medical emergency where the blood supply to the heart is suddenly blocked
• have a history of non-arteritic anterior ischaemic optic neuropathy – an eye condition that causes a sudden loss of vision

Side effects

PDE-5 inhibitors can cause some side effects, including:

• headaches and migraines
• flushing (redness) 
• indigestion
• nausea (feeling sick)
• vomiting (being sick)
• a blocked or runny nose
• back pain
• vision disturbances
• muscle pain

See the medicines information for erectile dysfunction.

NHS prescriptions

Your GP can prescribe sildenafil to anyone with erectile dysfunction as long as it is safe to do so (see warnings above). Other PDE-5 inhibitors may only be prescribed based on your individual circumstances.

In some cases you may need to pay the full cost of the medication. The exact price will depend on the dosage and your local pharmacy but four PDE-5 tablets usually cost between £17 and £30.

Read more about help with prescription costs.

Men with the following medical conditions are entitled to NHS prescriptions for PDE-5 inhibitors:

• diabetes 
• multiple sclerosis 
• Parkinson’s disease 
• polio 
• prostate cancer
• spina bifida 
• certain genetic conditions, such as Huntington's disease

Men who are receiving or have received certain medical treatments may also be entitled to NHS prescriptions for PDE-5 inhibitors. These treatments include:

• pelvic surgery – which is often used to remove tumours (growths) or to treat conditions such as incontinence
• surgical removal of the prostate gland (prostatectomy) – which is often used to treat prostate cancer
• dialysis for kidney failure 
• kidney transplant 

In certain circumstances, some specialist centres may provide an NHS prescription for PDE-5 inhibitors. For example, if ED is causing you severe distress.

Vacuum pumps

A vacuum pump consists of a clear plastic tube that is connected to a pump, which is either hand or battery operated.

You place your penis in the tube and pump out all of the air. This creates a vacuum that causes the blood to fill your penis, making it erect. You then place a rubber ring around the base of your penis to keep the blood in place, allowing you to maintain an erection for around 30 minutes.

It may take several attempts to learn how to use the pump correctly, but they are usually effective. After using a vacuum pump, nine out of 10 men are able to have sex, regardless of the cause of their ED.

Considerations 

You should not use a vacuum pump if you have a bleeding disorder or if you are taking anticoagulant medicines, which reduce the ability of your blood to clot.

Side effects of vacuum pumps include pain or bruising, although these occur in less than a third of men.

Men who qualify for NHS prescriptions for erectile dysfunction treatments may be able to get a vacuum pump on the NHS (see above for more details). However, some men will need to buy one.

The Sexual Advice Association produces a number of factsheets, including one on vacuum pumps that provides details of companies that supply them.

Alprostadil

If your erectile dysfunction doesn't respond to treatment, or you are unable or unwilling to use PDE-5 inhibitors or a vacuum pump, you may be given a medicine called alprostadil. This is a synthetic (man-made) hormone that helps to stimulate blood flow to the penis.

Alprostadil is available as:

• an injection directly into your penis – this is called an intracavernosal injection
• a small pellet placed inside your urethra (the tube that carries urine from your bladder to the tip of your penis) – this is called urethral application

You may be trained to correctly inject or insert alprostadil. If your partner is pregnant, use a condom during sex if you are inserting alprostadil into your urethra.

Alprostadil will usually produce an erection after five to 15 minutes. How long the erection lasts will depend on the dose.

In men who did not respond to PDE-5 inhibitors, alprostadil injections were successful in 85 out of 100 men. Alprostadil inserted into the urethra is successful for up to two-thirds of men.

Warnings

Alprostadil should not be used:

• in men at risk of priapism (a painful erection that lasts for several hours) – for example, those with sickle cell anaemia
• alongside other erectile dysfunction medications 
• if you have a penile implant or if you have been advised to avoid sexual activity 

Urethral application may also not be used in:

• some men who have anatomical problems with their penis (conditions that affect the physical structure of the penis) 
• men who have infections of their penis, such as balanitis (inflammation of the head of the penis)

Side effects

Alprostadil can cause some side effects including:

• changes in your blood pressure
• dizziness
• headache
• pain in your penis 
• urethral burning or bleeding
• reactions at the site of the injection, such as swelling

See the Alprostadil medicines information for more information about this medicine.

NHS prescriptions

As with PDE-5 inhibitors, NHS prescriptions for alprostadil may only be available for men with particular health conditions or those receiving some types of medical treatments. If you need to pay the full prescription cost, a single injection of alprostadil costs around £8 to £22, depending on the dose. A single dose of alprostadil for urethral application is around £10. 

Hormone therapy

If a hormonal condition is causing erectile dysfunction, you may be referred to an endocrinologist (who specialises in the treatment of hormonal conditions).

Hormones are chemicals produced by the body. Many hormonal conditions can be treated using injections of synthetic (man-made) hormones to restore normal hormone levels.

Surgery

Surgery for erectile dysfunction is usually only recommended if all other treatment methods have failed. It may also be considered in:

• younger men who have experienced serious injury to their pelvic area – for example, in a car accident
• men with a significant anatomical problem with their penis

In the past, surgery was used if there was clear evidence of a blockage to the blood supply of the penis. The surgeon could unblock the blood vessels to restore a normal supply of blood. However, research now suggests that the long-term results of this type of surgery are poor, so it's unlikely to be used.

Penile implants

Penile implants are a type of surgery that may be considered. These can be:

• semi-rigid implants – which may be suitable for older men who do not have sex regularly
• inflatable implants – which consist of two or three parts that can be inflated to give a more natural erection

Penile implants are not usually available on the NHS and inflatable implants may be very expensive. However, around three-quarters of men report being satisfied with the results of this type of surgery.

Complications

As with all types of surgery, having penile implants inserted carries a risk of infection. If you take preventative antibiotics, the rate of infection is around two or three in 100. Mechanical problems with the implants may occur within five years in five per cent of cases. 

Psychological treatments

If your erectile dysfunction has an underlying psychological cause then you may benefit from a type of treatment called sensate focus.

If conditions such as anxiety or depression are causing your erectile dysfunction, you may benefit from counselling (a talking therapy).

Sensate focus

Sensate focus is a type of sex therapy that you and your partner complete together. It starts with you both agreeing not to have sex for a number of weeks or months. During this time, you can still touch each other, but not in the genital area (or a woman’s breasts). The idea is to explore your bodies knowing that you will not have sex.

After the agreed period of time has passed, you can gradually begin touching each other’s genital areas. You can also begin to use your mouth to touch your partner, for example, licking or kissing, them. This can build up to include penetrative sex.

You can find out more about sensate focus from the College of Sexual and Relationship Therapists (COSRT).

Psychosexual counselling

Psychosexual counselling is a form of relationship therapy where you and your partner can discuss any sexual or emotional issues that may be contributing to your erectile dysfunction. By talking about the issues, you may be able to reduce any anxiety that you have and overcome your erectile dysfunction.

The counsellor can also provide you with some practical advice about sex, such as how to make effective use of other treatments for erectile dysfunction to improve your sex life.

For information and advice about sexual arousal, read about good sex.

Psychosexual counselling may take time to work and the results achieved have been mixed.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is another form of counselling that may be useful if you have erectile dysfunction. CBT is based on the principle that the way you feel is partly dependent on the way you think about things. CBT helps you realise that your problems are often created by your mindset. It is not the situation itself that is making you unhappy, but how you think about it and react to it.

Your CBT therapist can help you to identify any unhelpful or unrealistic thoughts that may be contributing to your erectile dysfunction – for example, to do with:

• your self-esteem (the way you feel about yourself) 
• your sexuality 
• your personal relationships

Your CBT therapist will be able to help you to adopt more realistic and helpful thoughts about these issues.

Read more about cognitive behavioural therapy.

Pelvic floor muscle exercises

Some studies have suggested that, in a few cases, it may be beneficial to exercise your pelvic floor muscles. These are a group of muscles around the underside of the bladder and rectum, as well as at the base of the penis.

Pelvic floor muscle exercise involves strengthening and training the muscles used to control the anus (back passage) and urinate. If your GP feels this type of exercise could be beneficial, then you may want to discuss it with a physiotherapist to learn it correctly.

By strengthening and training these muscles, you may be able to reduce the symptoms of erectile dysfunction.

Complementary therapies

Some complementary therapies, such as acupuncture, have claimed to treat erectile dysfunction. However, there is little evidence they are useful.

In some cases, they may even include ingredients that could interact with other medications and cause side effects.

Always speak to your GP before using any complementary therapies.

Counselling may be required if the underlying cause of your erectile dysfunction is psychological  

Page last reviewed: 23/09/2014

Next review due: 23/09/2016

Source: NHS Choices, UK

Treating ejaculation problems 

If you have ejaculation problems caused by physical conditions, your GP should be able to suggest possible treatment options.

Treating ejaculation problems caused by psychological factors can be more challenging, but most men who persevere with treatment have successful outcomes.

Premature ejaculation

Self-help

There are a number of things you can try yourself before seeking medical help, such as:

• masturbating an hour or two before having sex
• using a thick condom to help decrease sensation
• taking a deep breath to briefly shut down the ejaculatory reflex (an automatic reflex of the body during which ejaculation occurs)
• having sex with your partner on top (to allow them to pull away when you are close to ejaculating)
• taking breaks during sex and thinking about something boring

Couples therapy

If you are in a long-term relationship, you may benefit from having couples therapy. The purpose of couples therapy is two-fold.

First, couples are encouraged to explore issues that may be affecting their relationship, and given advice about how to resolve them.

Second, couples are shown techniques that can help the man to ‘unlearn’ the habit of premature ejaculation. The two most popular techniques are the ‘squeeze technique’ and the ‘stop-go technique’.

In the squeeze technique, the woman begins masturbating the man. When the man feels that he is almost at the point of ejaculation, he signals to the woman. The woman stops masturbating him, and squeezes the head of his penis for between 10 to 20 seconds. She then lets go and waits for another 30 seconds before resuming masturbation. This process is carried out several times before ejaculation is allowed to occur.

The stop-go technique is similar to the squeeze technique except that the woman does not squeeze the penis. Once the man feels more confident about delaying ejaculation, the couple can begin to have sexual intercourse, stopping and starting as required.

These techniques may sound simple, but they do require a lot of practice.

Medication to treat premature ejaculation

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are primarily designed to treat depression, but they also have the useful side effect of delaying ejaculation. Although SSRIs are not licensed to treat premature ejaculation, they are increasingly being prescribed for this use.

SSRIs used for this purpose include:

• paroxetine
• sertraline
• fluoxetine

Some men with premature ejaculation may experience an improvement in their symptoms as soon as treatment begins. However, you will usually need to take the medication for one to two weeks before you notice the full effects of the treatment.

Common side effects of SSRIs include:

• fatigue
• feeling sick and being sick
• diarrhoea 
• excessive sweating

However, these are usually mild and should improve after two to three weeks.

Dapoxetine

An SSRI, known as dapoxetine, has been specifically designed to treat premature ejaculation.

From November 2013, dapoxetine (Priligy) became the first medication to be licensed for premature ejaculation in the UK and local NHS authorities can choose to prescribe it on the NHS.

Dapoxetine acts much faster than the SSRIs mentioned above and can be used 'on demand'. If you are prescribed dapoxetine, you will usually be advised to take it one to three hours before having sex, but not more than once a day.

Dapoxetine is not suitable for all men diagnosed with premature ejaculation. For example, it is not recommended for some men with heart, kidney and liver problems. Dapoxetine can also interact with other medications, such as other antidepressants.

Common side effects of dapoxetine include headaches, dizziness and feeling sick.

Topical anaesthetics and condoms

The use of topical anaesthetics such as lidocaine or prilocaine can be helpful but can be transferred and absorbed to the vagina, causing decreased sensation. Condoms can also be used and are effective, particularly when combined with local anaesthesia.

Delayed ejaculation

Sex therapy

Sex therapy is a form of counselling that uses a combination of psychotherapy and structured changes in your sex life. This can help to increase your feeling of enjoyment during sex, and help make ejaculation easier.

Some clinical commisioning groups (CCGs) provide a sex therapy service on the NHS, but others do not. Therefore, levels of availability can vary widely depending on where you live.

You can also pay privately for sex therapy. Prices for a single session can vary from around £50 to £80. For information about private sex therapists in your local area you should visit the College of Sexual and Relationship Therapists website.

The relationship counselling service Relate also offers sex therapy at a number of its centres; you would be expected to pay for each session.

During sex therapy, you will have the opportunity to discuss any emotional or psychological issues related to your sexuality and relationship, in a non-judgemental way.

Activities may also be recommended for you to try at home while you are having sex with your partner (you should never be asked to take part in any sexual activities during a session with the therapist).

These may include:

• viewing erotic material before having sex, such as videos and magazines, to increase the feeling of sexual stimulation
• erotic fantasies and ‘sex games’ to make your lovemaking more exciting
• using lubricating creams or gels to make the physical act of sex more comfortable and relaxing
• using sexual aids, such as vibrators, to increase pleasure

Read more information about what a sex therapist can do.

Switching medication

There are a number of medications that can be used if it is thought SSRIs are responsible for causing delayed ejaculation. These include:

• amantadine – a medication originally designed to treat viral infections
• buproprion – a medication originally designed to help people stop smoking
• yohimbine – a medication originally designed to treat erectile dysfunction

These medications help block some of the chemical effects of SSRIs that are thought to contribute towards delayed ejaculation.

Retrograde ejaculation

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not have adverse effects on their health.

If retrograde ejaculation is caused by using a certain medication then normal ejaculation will usually return once the medication is stopped. Speak to your GP before you stop taking prescibed medication.

If treatment is required (usually because of wanting to father a child), medicines can be used to strengthen the muscles around the bladder neck. Pseudoephedrine (a medicine commonly used as a decongestant) has proved to be effective in treating retrograde ejaculation caused by diabetes or surgery.

However, if the retrograde ejaculation has been caused by significant muscle or nerve damage, treatment may not be possible.

Men who want to have children can have sperm taken from their urine for use in artificial insemination or in-vitro fertilisation (IVF).

Page last reviewed: 15/07/2014

Next review due: 15/07/2016

Source: NHS Choices, UK

Introduction 

Ejaculation problems, such as premature ejaculation, are common sexual problems in men.

The three main problems are:

• premature ejaculation 
• delayed ejaculation 
• retrograde ejaculation 

These are described in more detail below.

Premature ejaculation

Premature ejaculation is the most common ejaculation problem. It is where the male ejaculates too quickly during sexual intercourse.

Many men are unsure about how long ‘normal’ sex should last before ejaculation. A study looking at 500 couples from five different countries found the average time between a man putting his penis into his partner’s vagina and ejaculation was around five-and-a-half minutes.

However, it's up to the individual and his partner to decide whether or not they're happy with the time it takes for him to ejaculate. There is no definition of how long intercourse should last.

Occasional episodes of premature ejaculation are common and not a cause for concern. However, if you're finding that around half of your attempts to have intercourse result in premature ejaculation, it might help to get treatment.

Most men with this problem won't have always had it – they'll have previously ejaculated normally. This may be referred to as 'secondary' premature ejaculation.

It's less common for the man to have always experienced premature ejaculation (since becoming sexually active) – this is known as 'primary' or lifelong premature ejaculation. It affects around one in 50 men in England. In most cases of lifelong premature ejaculation:

• there is an inability to delay ejaculation during sex every time or most times
• the condition causes feelings of shame or frustration and impacts on quality of life, causing the man to avoid sexual intimacy

Delayed ejaculation

Delayed ejaculation (male orgasmic disorder) is classed as either:

• experiencing a significant delay before ejaculation is possible
• being unable to ejaculate at all even though the male wants to and his erection is normal

There is no set definition to describe ‘how long is too long’, but a persistent (and unwanted) delay of ejaculation that lasts for 30 to 60 minutes may suggest delayed ejaculation.

Alternatively, if you are unable to achieve ejaculation at least half the times you have sex, you may have delayed ejaculation.

As with premature ejaculation, delayed ejaculation can be either acquired or lifelong. Lifelong delayed ejaculation is less common and affects an estimated one in 1,000 men.

Delayed ejaculation can occur in all sexual situations, or just in certain situations – for example, you may be able to ejaculate normally when masturbating, but not during sex. When delayed ejaculation only happens in certain situations, there's usually a psychological cause.

Retrograde ejaculation

Retrograde ejaculation is a rarer type of ejaculation problem. It happens when sperm travels backwards and enters the bladder instead of coming out of the end of the urethra (the tube through which urine passes).

The main symptoms of retrograde ejaculation include:

• producing no semen, or only a small amount, during ejaculation
• producing cloudy urine (because of the semen in it) when you first go to the toilet after having sex

Men with retrograde ejaculation still experience the feeling of an orgasm and the condition does not pose a danger to health. However, it can affect the ability to father a child (read about infertility).

Treating ejaculation problems

Premature ejaculation can be treated with medication, such as the selective serotonin reuptake inhibitors (SSRIs) type of antidepressant, which can help delay ejaculating.

Couples therapy, a form of counselling, can be useful in coming up with techniques for partners to practice to help delay ejaculation.

Recommended treatments for delayed ejaculation depend on the underlying cause. If it is thought to be a side effect of medication, switching to an alternative medication will help. However, if the cause is thought to be psychological, counselling may be recommended.

Most men do not require treatment for retrograde ejaculation because they are still able to enjoy a healthy sex life and the condition does not affect their health. In some cases, medication may be used to help restore normal ejaculation.

However, if you want to have children, you may need fertility treatment to extract a sample of sperm.

Read more about treating ejaculation problems.

What causes ejaculation problems?

Ejaculation problems are complex and can be caused by a number of things, including:

• stress
• relationship problems
• anxiety – such as a man being anxious that he will lose his erection (erectile dysfunction), causing him to ‘rush’ the intercourse
• previous traumatic sexual experiences
• depression
• some medical conditions or medicines – for example, diabetes can cause delayed ejaculation

Some researchers think certain men are more prone to premature ejaculation because of their biological make-up, such as having an unusually sensitive penis.

Retrograde ejaculation is caused by damage to nerves or muscles that surround the neck of the bladder (the point where the urethra connects to the bladder). This damage can often occur as a complication of prostate or bladder surgery.

Read more about the causes of ejaculation problems.

Who is affected

Premature ejaculation is the most common type of ejaculation problem.

A number of surveys have found around one in three men reported being affected by premature ejaculation. The true figure is probably much higher as many men are reluctant to admit they have this problem.

While less common, delayed ejaculation is probably more of a problem then most people realise. One study found around one in 20 people had problems achieving an orgasm over the course of a month during the past year.

Although retrograde ejaculation is rare, it can be a common complication of some types of surgery, such as prostate surgery, or in men with certain health conditions that can damage the nerves, such as diabetes or multiple sclerosis.

The male midlife crisis

The male midlife crisis is something people joke about, but it can be distressing for those going through it

Page last reviewed: 15/07/2014

Next review due: 15/07/2016

 Source: NHS Choices, UK

Page last reviewed: 05/06/2014

Next review due: 04/06/2016

 Source: NHS Choices, UK

Why can’t I get and keep an erection?

Page last reviewed: 11/11/2014

Next review due: 10/11/2016

Source: NHS Choices, UK

Page last reviewed: 20/04/2015

Next review due: 20/04/2017

 Source: NHS Choices, UK

What should I do if my erection won’t go down?

Page last reviewed: 27/11/2014

Next review due: 26/11/2016

 Source: NHS Choices, UK

Introduction 

Priapism is a persistent and often painful erection that lasts for several hours.

The erection is not necessarily related to sexual stimulation or excitement, and does not subside after ejaculation (when semen is released from the penis).

The erection lasts longer than four hours. During this time, the shaft of the penis is rigid and inflexible, but the head of the penis (the glans) is usually soft. The penis is also usually painful or tender.

Priapism is a medical emergency – you should seek immediate medical assistance if you think you have it.

If it's not treated within 24 hours, your penis may be permanently damaged and you may have difficulties getting an erection in the future.

Types of priapism

There are three main types of priapism:

• low blood flow (ischaemic) priapism – the most common and serious type of priapism usually caused by lack of blood flow through the penis
• high blood flow (non-ischaemic) priapism – much rarer and usually caused by an injury to the genitals or perineum (the area in between the genitals and anus)
• recurrent or intermittant (stuttering) priapism - similar to ischaemic priapism but characterised by recurrent, long-lasting, painful erections that ease after 2-3 hours.

What causes priapism?

Priapism happens when blood that fills the spongy tissue of the penis during an erection is unable to flow out of the penis.

Anything that affects the nervous system or blood flow (or both) can trigger priapism. It can occur, for example, as a complication of sickle cell anaemia (a genetic blood disorder), or as a rare side effect of several other medications, such as antipsychotic agents or anticoagulants.

Read more about the causes of priapism and how priapism is diagnosed.

Treating priapism

If you have ischaemic (low blood flow) priapism, the sooner you receive treatment, the more effective it is likely to be.

Aspiration, a procedure that uses a needle and syringe to drain the blood out of your penis, is usually recommended.

If this does not work, medication may be injected into your penis which squeezes the blood vessels and helps push the blood out of your penis.

Surgery is only recommended if other treatments have failed. There are a number of different surgical procedures available, depending on the type of priapism you have.

Read more about how priapism is treated.

 Source: NHS Choices, UK

Male sexual dysfunction

Don't suffer in silence with erection problems or premature ejaculation: find out the causes and treatments

Page last reviewed: 10/02/2015

Next review due: 10/02/201

 Source: NHS Choices, UK

What is gynaecomastia?

Gynaecomastia (sometimes referred to as "man boobs") is a common condition that causes boys’ and men’s breasts to swell and become larger than normal. It is most common in teenage boys and older men.

What are the signs of gynaecomastia?

Signs vary from a small amount of extra tissue around the nipples to more prominent breasts. It can affect one or both breasts.

Sometimes, the breast tissue can be tender or painful, but this isn’t always the case.

What causes gynaecomastia?

Gynaecomastia can have several causes.

Hormone imbalance

Gynaecomastia can be caused by an imbalance between the sex hormones testosterone and oestrogen. Oestrogen causes breast tissue to grow. While all men produce some oestrogen, they usually have much higher levels of testosterone, which stops the oestrogen from causing breast tissue to grow.

If the balance of hormones in the body changes, this can cause a man’s breasts to grow. Sometimes, the cause of this imbalance is unknown.

Obesity

Some growth in breast tissue is not due to extra body fat from being overweight, so losing weight or doing more exercise may not improve the condition. However, a common reason for gynaecomastia is that being very overweight (obese) can increase levels of oestrogen, which can cause breast tissue to grow.

Newborn baby boys

Gynaecomastia can affect newborn baby boys, because oestrogen passes through the placenta from the mother to the baby. This is temporary and will disappear a few weeks after the baby is born.

Puberty

During puberty, boys’ hormone levels vary. If the level of testosterone drops, oestrogen can cause breast tissue to grow. Many teenage boys have some degree of breast enlargement. Gynaecomastia at puberty usually clears up as boys get older and their hormone levels become more stable.

Older age

As men get older, they produce less testosterone. Older men also tend to have more body fat, and this can cause more oestrogen to be produced. These changes in hormone levels can lead to excess breast tissue growth.

Other causes

In rare cases, gynaecomastia can be caused by:

• side effects of medication – such as anti-ulcer drugs or medication for heart disease
• illegal drugs – such as cannabis or anabolic steroids
• drinking too much alcohol
• a health abnormality – such as kidney failure or liver disease
• Klinefelter’s syndrome (a rare genetic disorder)
• lumps or infection in the testicles

Treatment for gynaecomastia

If you’re worried about breast tissue growth, see your GP.

If your GP thinks treatment is needed, there are two types of treatment for gynaecomastia:

• surgery to remove the excess breast tissue
• medication to adjust a hormone imbalance

Your GP can discuss the treatment options with you. Read more about male breast reduction surgery.

Procedures such as breast reduction surgery are not usually available on the NHS, unless there is a clear medical need for them. For example, if you have had gynaecomastia for a long time, it has not responded to other treatments and it is causing you a lot of distress or pain, your GP may refer you to a plastic surgeon to discuss the possibility of surgery.

Always see your GP if the area is very painful or there is an obvious lump. Sometimes, the lump may need to be removed. Gynaecomastia is not related to breast cancer, but if you're worried about breast swelling, see a GP.

Read the answers to more questions about men’s health.

Further information:

• Is my penis the right size and shape?
• Male breast reduction surgery 
• Teen boys’ health
• Puberty 
• Men’s Health Forum: male breast reduction 

Source: NHS Choices, UK

The male midlife crisis is often made fun of, but for many men it is a distressing experience.

'A time of growth'

When it comes to the midlife crisis, Dr Milne says everyone's circumstances are different.

"I would guess it affects a significantly small amount of the population. Somewhere around 20% of people (mostly men) will have gone through this by the time they're 50.

"My book is all about coping," he says, "and if I was giving advice on how to cope, I'd suggest telling your GP you're feeling depressed, because depression makes up a significant portion of the midlife crisis."

"I would, however, recommend that you see a psychologist or counsellor and have it treated as a psychological condition and not through medication."

Dr Milne says the important thing is to thrive. "Even if there are times when all you feel you can do is survive to the next day, the goal is thriving, and I believe that we do this best when we view our current crisis as a time of growth and personal change."

The best advice is to see your GP and get help. Depression can be triggered by a major life change, such as divorce, separation, long-term illness, bereavement or job loss. Sometimes there appears to be no obvious reason.

The point is, if you feel very low for more than a couple of weeks, it is vital that you go to your GP for help. You may be prescribed antidepressants or referred to a counsellor.

Ways to help avoid depression include taking regular exercise, which can ease tension and trigger brain chemicals that improve your mood (endorphins), eating well and sleeping well. Most of all, don't bottle up your feelings.

• For tips on looking after your emotional health, read Men and emotional health.
• If you are worried about your health have a look at the Man MOT, a confidential online surgery where you can talk to a GP anonymously.

Sexual arousal in women

 

During arousal and sex, there are various stages of physical response. Researchers have identified four stages of sexual response in women and men: arousal, plateau, orgasm and resolution. This article describes what happens in a woman's body when she is sexually aroused.

 

Stage 1: excitement or arousal

When a woman becomes aroused (turned on), the blood vessels in her genitals dilate. There is increased blood flow in the vaginal walls, which causes fluid to pass through them. This is the main source of lubrication, which makes the vagina wet.

The external genitalia or vulva (including the clitoris, vaginal opening, and inner and outer lips or labia) become engorged (swollen) due to the increased blood supply. Inside the body, the top of the vagina expands.

The pulse and breathing quicken, and blood pressure rises. A woman may become flushed, especially on the chest and neck, due to the blood vessels dilating.

Stage 2: plateau

Blood flow to the lower third of the vagina reaches its limit, and causes the lower area of the vagina to become swollen and firm. This is called the introitus, sometimes known as the orgasmic platform, and undergoes rhythmic contractions during orgasm. 

A woman’s breasts may increase in size by up to 25%, and blood flow to the area around the nipple (the areola) increases, making the nipples look less erect.

As a woman gets closer to orgasm, her clitoris pulls back against the pubic bone and seems to disappear. Continuous stimulation is needed in this phase to build up enough sexual excitement for orgasm. 

Stage 3: orgasm

Orgasm is the intense and pleasurable release of sexual tension that has built up in the earlier stages, characterised by contractions (0.8 seconds apart) of the genital muscles, including the introitus. Read more here: what is an orgasm? 

Most women don’t experience the recovery period that men do after an orgasm. A woman may have another orgasm if she's stimulated again.

Not all women have an orgasm every time they have sex. For most women, foreplay is an important role in an orgasm occurring. This can include stroking erogenous zones and stimulating the clitoris.  

Stage 4: resolution

This is when the woman's body slowly returns to its normal state. Swelling reduces, and breathing and heart rate slow down. 

Female ejaculation

Female ejaculation is an uncommon condition where a woman expels clear fluid from her vagina during sex. In this video, an expert explains more and members of the public give their thoughts. Part of the embarrassing conditions series.

Page last reviewed: 02/06/2014

Next review due: 01/06/2016

Why does sex hurt?

Pain during or after sex (dyspareunia) can be caused by many things, such as:

• illness
• infection
• a physical problem
• a psychological problem

If you get pain during or after sex, your body may be trying to tell you something is wrong, so don't ignore it. See your GP or go to a sexual health (genitourinary medicine or GUM) clinic.

If you find talking about it embarrassing, remember that doctors are used to dealing with problems like this.

Pain during sex can affect both men and women.

Painful sex in women

Women can experience pain during or after sex, either in the vagina or deeper in the pelvis. Pain in the vagina could be caused by:

• an infection: thrush or a sexually transmitted infection (STI), such as chlamydia, gonorrhoea or genital herpes
• the menopause: changing hormone levels can make your vagina dry (atrophic vaginitis)
• lack of sexual arousal at any age
• vaginismus: a condition where muscles in or around the vagina shut tightly, making sex painful or impossible
• genital irritation or allergy caused by spermicides, latex condoms or products such as soap and shampoo

Pain felt inside the pelvis can be caused by conditions such as:

• pelvic inflammatory disease (PID)
• endometriosis
• fibroids growing near your vagina or cervix
• irritable bowel syndrome (IBS)
• constipation

Painful sex in men

Some causes of painful sex for men are:

• infections like thrush, which can cause soreness and itching, and some STIs, such as herpes
• if the foreskin is tight, penetration can be painful, as the foreskin is pushed back
• small tears in the foreskin that can't be seen but cause soreness and a sharp, stinging pain around the tear
• inflammation of the prostate gland (prostatitis)
• testicle pain and swelling can sometimes be caused by getting sexually aroused but not ejaculating (coming). It can also be a sign of an infection, such as chlamydia.

What to do

If you have pain during or after sex, you should get advice from your GP or a GUM clinic. They can assess what’s causing the problem and whether you need any treatment. For example:

• if you have pain, unusual discharge, itchiness or soreness around your genitals, they may recommend treatment for thrush or having an STI test
• if your vagina is dry, you may be advised to try using a lubricating product – remember to use a water-based product if you’re using condoms, because oil-based lubricants can damage them and make them ineffective
• if you have an allergy or irritation around your genitals, you may be advised to avoid using products that could be causing it
• if there’s an emotional reason or anxiety that's causing problems, a counsellor or sex therapist may be able to help –  your GP or sexual health clinic can refer you to one 

Read the answers to more questions about sexual health.

Further information:

• Is sex painful the first time?
• Is masturbation normal?
• Cystitis
• Sexually transmitted infections (STIs)
• Penis problems – a visual guide
• Good sex
• Female sexual problems
• Male sexual problems
• Find a sexual health (GUM) clinic
• Sexual Advice Association: Painful sex or dyspareunia (PDF, 88kb, opens in a new window)

Page last reviewed: 05/05/2015

Next review due: 04/05/2017

Source: NHS Choices, UK

Vaginismus

Introduction 

Vaginismus is the term used to describe recurrent or persistent involuntary tightening of muscles around the vagina whenever penetration is attempted.

It can disrupt or completely stop your sex life, and can lead to distress, a loss of confidence and relationship problems. It may even prevent you starting a family.

The condition can also make gynaecological and pelvic examinations difficult or impossible.

The symptoms can vary from one woman to the next. Some women are unable to insert anything into their vagina because it closes up completely, while others can insert a tampon but are unable to have penetrative sex, and other women are able to have sex but find it very painful.

Read more about the symptoms of vaginismus.

When to seek medical help

See your GP or visit a sexual health clinic if you think you might have vaginismus. You may feel embarrassed about seeking help, but vaginismus is a common sexual problem that can get better with appropriate support and treatment.

If your GP or doctor suspects vaginismus, they may be able to refer you to a specialist who can treat the problem, such as a doctor with training in sexual medicine, a gynaecologist, or a sex therapist.

Read more about diagnosing vaginismus.

What causes vaginismus?

Many factors can play a part in the development of vaginismus, although it's not fully understood why the condition happens.

Factors can include:

• thinking the vagina is too small
• negative sexual thoughts (thinking sex will be painful and cause damage)
• previous sexual abuse
• damage to the vagina (for example, during childbirth or an episotomy)
• painful conditions of the vagina and surrounding area, such as vulvodynia (see below)
• painful first intercourse
• relationship problems
• fear of pregnancy

Vulvodynia is the term used to describe the sensation of vulval burning, soreness or pain in the absence of any obvious skin condition or infection. Symptoms may be constant (unprovoked vulvodynia) or only occur with touch, inserting a tampon or penetrative sex (provoked vulvodynia). 

Provoked vulvodynia can lead to vaginismus.

Read more about the causes of vaginismus.

How vaginismus is treated

Vaginismus can be treated. How it's treated will depend on the cause.

If there's an obvious physical cause, such as an infection, it can be treated with appropriate medication.

If the cause is psychological, sex therapy may be recommended. This may include counselling, brief dynamic psychoanalysis, or cognitive behavioural therapy (CBT), as well as treatments such as vaginal trainers and relaxation techniques.

Vaginal trainers are smooth, cylindrical dome-tipped shapes, usually made of plastic and in four graduated sizes that allow gentle progression of treatment. They can be used at home to help you get used to having something inserted into your vagina.

Read more about treating vaginismus.

Vaginismus - Treatment

Treating vaginismus 

Treatment for vaginismus will largely depend on what's causing it.

If there is an obvious physical cause, such as an infection or oversensitive nerves at the opening of the vagina (provoked vulvodynia), this may be treated with medication at the same time the vaginismus is treated.

If the cause is less obvious, you may be taught self-help techniques to try to resolve the problem.

Sex therapy

A specialist in psychosexual medicine or sex therapy may offer you sex therapy in the form of counselling, brief dynamic psychoanalysis, or cognitive behavioural therapy (CBT). 

These therapies can help to address any underlying psychological issues, such as fear or anxiety, tackle any irrational or incorrect beliefs that you have about sex and, if necessary, be used to educate you about sex.

Sex therapy is available privately. In many parts of the UK, it's no longer available through the NHS.

The specialist can also talk to you about techniques that can eventually stop your vagina closing involuntarily, such as using vaginal trainers and pelvic floor exercises.

Vaginal trainers

Vaginal trainers can be used to help you relax the muscles in your vagina by gradually getting you used to having something inserted into it. These are a set of four smooth, plastic penis-shaped objects in different sizes, which can be used in the privacy of your own home.

The smallest trainer is inserted first, using a lubricant if needed. Once you feel comfortable inserting the smallest one, you can move on to the second size and so on. It's important to go at your own pace, and it doesn't matter how long it takes – whether it's days, weeks, or months.

When you are able to tolerate the larger trainer without any pain or feelings of anxiety, you and your partner may want to try having sex.

Vaginal trainers are not used to "stretch" a vagina that is "too narrow". Women with vaginismus have normal-sized vaginas. The trainers are simply a method of teaching the vagina to accept penetration without automatically closing.

If you prefer, you can try using your fingers instead of vaginal trainers.

Relaxation and touching

You may also find that relaxation and exploration exercises help. Having a bath, massage and breathing exercises are good ways to relax while you get to know your body.

Your therapist may also teach you a technique called progressive relaxation. This involves tensing and relaxing different muscles in your body in a particular order. You can then practise tensing and relaxing your pelvic floor muscles before trying to insert your finger or a cone.

If you reach the stage where you can put your finger inside your vagina, you can try to insert a tampon, using lubricant if needed.

It's important to take things slowly and gently and, when you are ready for intercourse, make sure you are fully aroused before attempting penetration.

Pelvic floor exercises

A physiotherapist may be able to teach you pelvic floor exercises, such as squeezing and releasing your pelvic floor muscles, that can help you gain control over the muscles causing the vagina to close involuntarily.

These exercises are usually recommended while using vaginal trainers.

Occasionally, a technique called biofeedback may be recommended. A small probe is inserted into your vagina, which monitors how well you are doing the exercises by giving you feedback as you do them. The probe senses when you squeeze your muscles and sends the information to a monitor.

However, biofeedback isn’t always available, and some practitioners don't consider this approach to be useful.

Sensate focus

If you are in a relationship, you could try sensate focus. This is a type of sex therapy that you and your partner do together. It starts with you both agreeing not to have sex for a number of weeks or months. During this time, you can still touch each other, but not in the genital area (or a woman's breasts). The idea is to explore your bodies, knowing that you will not have sex.

After the agreed period of time, you gradually start touching each other's genital areas, which should eventually build up to penetrative sex.

Surgery

Very few cases of vaginismus require surgery. However, it may be useful if a physical problem is causing pain during sex and is contributing to your vaginismus.

Treating endometriosis

Endometriosis is a possible reason for surgery, as it can cause pain in the pelvis during sex.

Endometriosis causes small pieces of your womb lining to grow outside your womb. Surgery can be used to remove or destroy these areas of tissue. Read more about treating endometriosis.

Enlarging the vagina

Surgery is sometimes used to enlarge the vagina. This may be necessary if, for example, previous surgery has left scar tissue that either restricts or blocks your vagina, such as an episiotomy during childbirth.

A small operation can remove the scar tissue. It involves neatly cutting out the scar tissue and sewing together the clean-cut edges using small, dissolvable stitches. The operation can either be carried out under a local anaesthetic or a general anaesthetic.

Page last reviewed: 09/01/2015

Next review due: 09/01/2017

 Source: NHS Choices, UK

Vaginal Health

Vagina health

Find out about vaginas, from keeping clean and healthy to what's normal and what's not. Includes changes after childbirth

Keeping your vagina clean and healthy

 

The vagina is designed to keep itself clean with the help of natural secretions (discharge). Find out how to help your vagina keep clean and healthy – and why you don’t need douches or vaginal wipes.

The vagina is a tube of muscle inside a woman’s body that runs from the cervix (the opening of the womb) to the vaginal opening. The external sex organs, which are called the vulva, surround the vaginal opening.

Looking after your everyday health can help keep your vagina in good shape, says Dr Suzy Elneil, consultant in urogynaecology at University College Hospital, London, and spokesperson for Wellbeing of Women. “Generally, good vaginal health is maintained by making sure you’re in good general health,” she explains. “This includes healthy diet and exercise. Normal exercise helps maintain good vaginal function, as walking and running helps the pelvic floor to tone up and helps ensure good general health.”

Find out more about having a healthy diet, exercise and keeping fit, and pelvic floor exercises.

Vaginal secretions or discharge

Other than your period as part of your natural menstrual cycle, it’s normal to produce clear or white secretions (discharge) from your vagina. This mucus is produced naturally from the neck of the womb, known as the cervix.

“Vaginal discharge is not ‘always a bad sign’,” says Dr Elneil. “There is a myth that copious clear or white discharge is associated with sexually transmitted infections. Changes in the amount of discharge can be 100% hormonal – in other words, linked to the menstrual cycle, pregnancy or menopause.”

The character and amount of vaginal discharge varies throughout your menstrual cycle. Around the time that your ovary releases an egg (ovulation), your discharge usually becomes thicker and stretchy, like raw egg white.

Healthy discharge doesn’t have a strong smell or colour. You may feel an uncomfortable wetness, but you shouldn’t have any itching or soreness around your vagina. If there are any changes to your discharge that aren’t normal for you, such as a change in colour or if it starts to smell or itch, see your GP as you might have an infection.

You can find out more about vaginal discharge, pregnancy and the menopause.

Bacteria in the vagina

There are lots of bacteria inside the vagina, and they’re there to protect it. Professor Ronnie Lamont, spokesperson for the Royal College of Obstetricians and Gynaecologists, says: “The vagina contains more bacteria than anywhere else in the body after the bowel, but the bacteria are there for a reason.”

The good bacteria inside the vagina:

• provide "numerical dominance": they outnumber other potential harmful bacteria that might enter the vagina
• help to keep the vagina’s pH balance (how acidic the vagina is) at an even level, which helps to keep the balance of bacteria healthy
• can produce bacteriocins (naturally occurring antibiotics) to reduce or kill other bacteria entering the vagina
• produce a substance that stops invading bacteria sticking to the vagina walls, which prevents bacteria from invading the tissues

If the balance of bacteria is disturbed, this can lead to infection and inflammation. Bacteria called lactobacilli help to keep the vagina’s pH balance at its normal low level (less than pH 4.5), which also prevents the growth of other organisms. If the pH of the vagina increases (in other words, if it gets less acidic), the quality or amount of lactobacilli can fall and other bacteria can multiply. This can result in infections such as bacterial vaginosis or thrush, which can cause symptoms including itching, irritation and abnormal discharge.

Washing your vagina

It’s a good idea to avoid perfumed soaps, gels and antiseptics as these can affect the healthy balance of bacteria and pH levels in the vagina, and cause irritation.

Use plain, unperfumed soaps to wash the area around the vagina (the vulva) gently every day. The vagina will clean itself inside your body with natural vaginal secretions (discharge). “During your period, washing more than once a day may be helpful,” says Dr Elneil, who points out that keeping the perineal area (between the vagina and anus) clean is important too. “Good perineal hygiene is necessary, by washing that area at least once a day using your normal bathing routines.”

“All women are different,” says Professor Lamont. “Some may wash with perfumed soap and not notice any problems. But if a woman has vulval irritation or symptoms, then one of the first things you can do is to use non-allergenic, plain soaps to see if that helps.”

Vaginal douches

A douche flushes water up into the vagina, clearing out vaginal secretions. Some women use a douche to "clean" the vagina, but using a douche can disrupt the normal vaginal bacteria so it isn't recommended that you use one.

“I can’t think of any circumstances where douches are helpful, because all they do is wash out everything that’s in the vagina, including all the healthy bacteria,” explains Professor Lamont.

There is no evidence that douching protects against STIs or vaginal infections, and it may even increase the risk.

Scented wipes and vaginal deodorants

These perfumed products can disrupt the vagina’s healthy, natural balance. “If nature had intended the vagina to smell like roses or lavender, it would have made the vagina smell like roses or lavender,” says Professor Lamont.

Washing with water and a plain soap should be all you need to keep your vagina healthy. It’s normal for the vagina to have a scent. “Vaginal odour can change at different times of the reproductive cycle and shouldn’t always be thought of as being a sign of infection or illness,” says Dr Elneil.

If you’re worried about the way your vagina smells, if the smell is unpleasant, or you’re using perfumed products to cover up your vagina’s smell, you should see your GP. You might have an infection that needs treatment.

The most common cause of unusual vaginal discharge is bacterial vaginosis, which can cause an unpleasant smell. It’s easily treated with antibiotics, so see your GP if you’re worried.

You can find out more about symptoms of bacterial vaginosis, symptoms of thrush and symptoms that could signal a sexually transmitted infection.

Safer sex

Some bacteria and viruses can get into the vagina during sex. These include the bugs that cause chlamydia, gonorrhoea, genital herpes, genital warts, syphilis and HIV. You can protect your vagina against these infections by using a condom every time you have sex.

Find out some tips about using condoms.

Cervical screening

All women aged from 25 to 64 are invited for cervical screening. Being screened regularly means that any abnormal changes in the cervix can be identified early on and, if necessary, treated to stop cancer developing. Find out more about cervical screening.

Page last reviewed: 23/10/2013

Next review due: 23/10/2015

Source: NHS Choices, UK

You and your body just after birth

What can I do to help recover from tearing?

The first few days with your new baby can be a very emotional time for you and your partner. There's a lot to learn and do as new parents.

There is the excitement of getting to know your baby, but you will also be tired, and your body will be recovering from labour and the birth.

Keep your baby close to you as much as you can. Your partner could also spend time holding and being close to your baby. They may feel a little left out, especially if they have to leave you and your baby in hospital and go back to an empty house.

They may need a bit of support and encouragement to get involved. The more you can both hold and cuddle your baby, the more confident you will all feel.

Below you can find out more about:

How you'll feel after the birth

In hospital with your baby

Your body in the first few days

Stitches, piles and bleeding after birth

Avoiding deep vein thrombosis (DVT)

Postnatal exercises

Recovering from a caesarean

Checks and immunisations after birth

How you feel after the birth

You may feel tired for the first few days, so make sure you get plenty of rest. Even just walking and moving about can seem like hard work. Get some tips on coping with stitches, piles and bleeding. 

For a lot of mothers, the excitement and pleasure of the new baby far outweigh any problems. But you can begin to feel low or rather depressed, especially if you are very tired or feel you cannot look after your baby in the way you would like to.

Giving birth is an emotional and tiring experience, and your hormones change dramatically in the first few days. Some women get the "baby blues" and feel weepy around three to five days after giving birth. Feeling weepy can be worse if your labour was difficult, you are very tired, or you have other worries.

Make sure you and your partner know the signs of postnatal depression.

Some women worry because they don't love their baby immediately. But it's not always love at first sight. You may just need to give yourself time to bond with your baby. You can still care for your baby and provide all the warmth and security he or she needs in the meantime. 

In hospital with your baby

If you have your baby in hospital, you may be able to go home with your baby straight from the labour ward, or you may be moved to a postnatal ward, where you will be with other mothers and babies.

If your delivery is straightforward, your stay in hospital is likely to be short. It helps if you've discussed your postnatal care with your midwife during pregnancy so you know what to expect. Any preferences can then be recorded on your birth plan so staff on the postnatal ward are aware of them.

You'll probably need quite a lot of help and advice with your first baby. Whether you are in hospital or at home, the midwives are there to guide and support you, and also check you're recovering from the birth. Don't hesitate to ask for help if you need it.

A midwife will be available in your community to help you look after yourself and your baby. You can get help and support at a Children's Centre – find a Sure Start Children's Centre near you.

Your body in the first few days

Your body will have been through big changes over the past few days.

Your breasts

To begin with, your breasts will produce a nutritious yellowish liquid called colostrum for your baby. On the third or fourth day, they may feel tight and tender as they start to produce milk. Wearing a supportive nursing bra may help. Speak to your midwife if you're very uncomfortable.

Read more about breastfeeding in the first few days.

Your abdomen

Your abdomen (tummy) will probably be quite baggy after delivery. Despite delivering your baby and the placenta, you'll still be quite a lot bigger than you were before pregnancy.

This is partly because your muscles have stretched. If you eat a balanced diet and get some exercise, your shape should gradually return to normal.

Breastfeeding helps because it makes the womb (uterus) contract. Because of this, you may feel quite painful period-type cramps while you are feeding.

Find out about keeping fit and healthy with a baby.

Your bladder

It's quite common after having a baby to leak urine accidentally if you laugh, cough or move suddenly. Pelvic floor exercises can help with this. You can find out more about incontinence and where to get help on the Bladder and Bowel Foundation website.  

If the problem lasts for more than three months, see your doctor, who may refer you to a physiotherapist.

Stitches, piles and bleeding after birth

If you've had stitches after tearing or an episiotomy (cut), bathe the area often in clean, warm water to help it heal. Have a bath or shower with plain warm water. After bathing, dry yourself carefully.

In the first few days, remember to sit down gently and lie on your side rather than on your back.

If the stitches are sore and uncomfortable, tell your midwife as they may be able to recommend treatment. Painkillers can also help.

If you're breastfeeding, check with your midwife, GP or pharmacist before you buy over-the-counter painkillers, such as ibuprofen or paracetamol.

Stitches usually dissolve by the time the cut or tear has healed, but sometimes they have to be taken out.

Going to the toilet

At first, the thought of passing urine can be a bit frightening because of the soreness and because you can't feel what you're doing. Drinking lots of water dilutes your urine, but tell your midwife if you really find it difficult to pass urine.

You probably won't need to open your bowels (have a poo) for a few days after the birth, but it's important not to let yourself get constipated. Eat plenty of fresh fruit, vegetables, salad, wholegrain cereals and wholemeal bread, and drink plenty of water.

Whatever it may feel like, it's very unlikely that you'll break the stitches or open up the cut or tear again. It might feel better if you hold a pad of clean tissue over the stitches when doing a poo, and try not to strain.

Piles

Piles (haemorrhoids) are very common after birth, but they usually disappear within a few days. Eat plenty of fresh fruit, vegetables, salad, wholegrain cereals and wholemeal bread, and drink plenty of water. This should make bowel movements easier and less painful. Don't push or strain as this will make the piles worse. Let your midwife know if you feel very uncomfortable and they will be able to give you an ointment to soothe the piles.

Bleeding after the birth (lochia)

After the birth, you will bleed from your vagina. This will be quite heavy at first, and you'll need super-absorbent sanitary towels. Change them regularly, washing your hands before and afterwards. It isn't a good idea to use tampons until after your six-week postnatal check because they can cause infection.

See when you can start using tampons after birth.

While breastfeeding, you may notice that the bleeding is redder and heavier. You may also feel cramps like period pains, known as "after pains". These things happen because breastfeeding makes the womb (uterus) contract.

The bleeding will gradually become a brownish colour and may continue for some weeks, getting less and less until it stops. If you find you are losing blood in large clots, you should save your sanitary towels to show the midwife as you may need some treatment.

Avoiding deep vein thrombosis (DVT) after pregnancy

Deep vein thrombosis (DVT) is a serious condition where a clot develops in the deep veins of your legs. It can be fatal if the clot travels from your legs to your lungs.

Pregnant women and women who have had a baby in the past six weeks are among those who are more at risk of DVT. Flights that last more than five hours, where you sit still for a long time, may further increase your risk.

If you plan to travel by air, it's important to get advice from your GP or health visitor before the trip. They can give you advice on sitting exercises to keep your circulation moving.

If you develop a swollen, painful leg or have breathing difficulties after a trip, see your GP urgently or go to the nearest A&E department.

Postnatal exercises

Postnatal exercises will help to tone up the muscles of your pelvic floor and tummy, and help you get your usual shape back. They will also get you moving and feeling generally fitter. You may be able to attend a postnatal exercise class at your hospital. Ask your midwife or health visitor. 

See more about postnatal exercises.

Recovering from a caesarean

It takes longer to recover from a caesarean section than it does from a natural birth.

After a caesarean, you'll feel uncomfortable and will be offered painkillers. You will usually be fitted with a catheter (a small tube that goes up into your bladder) for up to 24 hours. You may be prescribed daily injections to prevent blood clots (thrombosis).

Depending on the help you have at home, you should be ready to leave hospital within two to four days.

You'll be encouraged to become mobile by getting out of bed and walking around as soon as possible, and your midwife or hospital physiotherapist will give you advice about postnatal exercises that will help you to recover.

You can drive as soon as you can move without pain as long as you can perform an emergency stop. This could take up to six weeks.

Read more about recovering from a caesarean.

Checks and immunisations after birth

After you've had your baby, you'll be offered some checks and immunisations.

Rubella

If you were not immune to rubella (german measles) when tested early in your pregnancy, you will usually be offered the measles, mumps and rubella (MMR) vaccine by your maternity team before you leave the maternity unit, or by your GP shortly afterwards.

If you aren't offered the vaccine, talk to your midwife or GP as this is a good opportunity to get it done. You shouldn't try to get pregnant again for at least one month after the injection, but it's safe for you to breastfeed.

If you're rhesus negative

If your blood group is rhesus negative, a blood sample will be taken from the umbilical cord after the birth to see if your baby is rhesus positive. If they are, you will be offered an injection to protect your next baby from something called rhesus disease.

The injection should be given within 72 hours of your baby being born. Speak to your doctors or midwives if you want to know more.

Find out about other sources of support after the birth and getting in touch with other new parents.

Page last reviewed: 25/02/2015

Next review due: 25/02/2017

Source: NHS Choices, UK

Vagina changes after childbirth

 

The vagina naturally changes after giving birth, and might feel wider, dry or sore for some time. Find out what to expect and the ways you can help speed recovery.

When you give birth, the baby travels through the cervix and out through the vagina (also called the birth canal). The entrance to the vagina must stretch to allow the baby through. Sometimes the skin between the vagina and anus (the perineum) might tear or be cut by a doctor or midwife to allow the baby out. This is called an episiotomy.

After having a baby, it’s not unusual for women to feel that their vagina is more loose or dry than usual, and to have perineal pain or pain during sex. This page lists a few of the changes you might notice and tips on what you can do.

Wider vagina

Your vagina might look wider than it did before, according to Dr Suzy Elneil, consultant in urogynaecology at University College Hospital, London. “The vagina can feel looser, softer and more ‘open’,” she says. It may also look and feel bruised or swollen. This is normal, and the swelling and openness should start to reduce a few days after your baby is born.

Your vagina will probably not return completely to its pre-birth shape, but this shouldn’t be a problem. If you’re worried, talk to your health visitor or GP.

“We always recommend pelvic floor exercises,” Dr Elneil says. Pelvic floor exercises (sometimes called Kegel exercises) help to tone the vaginal muscles and your pelvic floor muscles. This will help to prevent incontinence (urine leaking) and can help your vagina feel firmer. It's not uncommon for women to experience incontinence after childbirth, but pelvic floor exercises can help limit this. They can also help sex feel better.

You can do pelvic floor exercises anywhere and at any time, either sitting or standing up:

• Squeeze and draw in your anus at the same time, and close up and draw your vagina upwards.
• Do it quickly, tightening and releasing the muscles immediately.
• Then do it slowly, holding the contractions for as long as you can (but not more than 10 seconds) before you relax.
• Repeat each exercise 10 times, four to six times a day.

You may find it helps to imagine you’re stopping a bowel movement, holding in a tampon or stopping yourself urinating.

You could fit the exercises in while washing up, queuing in the supermarket or watching TV.

Dryness in the vagina

It’s normal for the vagina to feel drier than usual after childbirth. This is linked to the lower levels of oestrogen in your body compared to when you were pregnant.

For breastfeeding mothers, levels of oestrogen are lower than in those who aren’t breastfeeding and the dryness can be more marked. “Once you stop breastfeeding and your periods have returned, the levels of oestrogen revert to pre-pregnancy levels,” says Dr Elneil. "If you’ve noticed dryness, it should improve."

If the dryness bothers you, talk to your health visitor or GP. If you’ve started having sex again and the dryness is causing problems, you can use a lubricant – you can buy lubricant in pharmacies, supermarkets or online. If you’re using latex condoms, make sure the lubricant is water-based, because oil-based products (such as moisturiser and lotion) can make latex condoms tear or rip.

Try to talk about this with your partner if it’s causing problems in your sex life. That way, you can deal with it together rather than worrying about it on your own.

Soreness and stitches in the perineum

“The vaginal area can feel painful or sore in the immediate period after childbirth,” says Dr Elneil. “This usually improves within 6-12 weeks after the birth. We always recommend pelvic floor exercises to help make the situation better in this case, too.”

Your perineum can feel sore, especially if your skin tore or you needed stitches to repair a tear or episiotomy after giving birth. Painkillers can help, but if you’re breastfeeding talk to your midwife, GP or pharmacist before you buy any over-the-counter painkillers. It’s important to keep the perineal area clean, so always wash your hands before and after changing your sanitary pads and make sure you change them as soon as you need to. Have a bath or shower every day to keep your perineum clean.

If you’re worried about how your stitches are healing, talk to your health visitor or GP – this is especially important if you have a lot of pain or discomfort, or you notice a smell.

Depending on the size of the wound, you might have a scar when the tear or cut is healed. 

Pain during sex

There’s no right or wrong time to start having sex again after you’ve had a baby. Don’t rush into it. If sex hurts, it won’t be pleasurable. If your vagina feels dry, try a lubricant during sex to see if that helps.

If you have discomfort around your perineum, it might be worth your health visitor or GP having a look to check that it’s healing in the right way.

It’s not unusual to feel less like having sex than you used to – you’ve given birth, you’re looking after a tiny baby and you’re probably feeling very tired. It's important to talk about this with your partner, rather than just avoiding sex. If you both know what the situation is, you can deal with it together.

If you continue to feel pain during sex, talk to your GP.

Don’t forget to think about contraception after having a baby – it’s possible to get pregnant three weeks after giving birth.

Page last reviewed: 24/10/2013

Next review due: 24/10/2015

 Source: NHS Choices, UK

 

Girls' bodies Q&A

 

Puberty can be a confusing time because your body and your feelings are changing as you grow up. Here are answers to some of the questions that girls ask about their bodies.

Click on the questions below to go directly to the answer.

• At what age do you go through puberty?
• Is discharge from the vagina normal?
• My discharge smells. Is that normal? 
• When should you start your periods? 
• What should you use when your period starts? 
• Is my period normal? 
• What if my period is late? 
• Are my breasts too small? 
• How do I know if I have breast cancer? 
• When do I have to have a cervical screening test? 
• What is the hymen?
• Do you put on weight when you're on the Pill?
• Can you get pregnant if you have sex during your period? 
• What is the clitoris?

At what age do you go through puberty?

You'll probably start to notice changes from age 10 upwards, but there's no right or wrong time to start. Some people go through puberty later than others. This is normal. If you have no signs of puberty by the age of 16, see a doctor for a check-up.

Find out more about girls and puberty.

Is discharge from the vagina normal?

Yes, this is perfectly normal. Girls start to produce more vaginal discharge (fluid) as they go through puberty and the hormones in the glands of the vagina and cervix (neck of the womb) begin to work. The fluid helps to keep the vaginal area moist, and protects it from damage or infection.

Before puberty, most girls have very little discharge. After puberty, what's normal for one girl won't be normal for another. Some produce a lot of fluid and some produce very little.

When you start your periods, you'll probably notice that your discharge varies at different times during your menstrual cycle. It might be colourless or creamy white in colour, and it may become more sticky and increase in quantity. Find out about periods and the menstrual cycle.

My discharge smells. Is that normal?

It's not normal if the discharge becomes smelly or green, or if your vaginal area is itchy or sore. These may mean that you have an infection, such as thrush, which is common but easily treated. If you've had sex without using a condom, there's a risk you might have a sexually transmitted infection (STI).

If your discharge is different from what's normal for you, see a doctor or nurse. Advice is free and confidential, even if you're under 16.

Read how to keep your vagina clean and healthy.

When should you start your periods?

Girls usually start their periods between the ages of 10 and 16. Most girls start when they’re around 12. As everyone develops at different rates, there's no right or wrong age for a girl to start. Your periods will start when your body is ready, and there's nothing you can do to make them start sooner or later.

If you haven’t started your periods by the time you’re 16, visit your doctor for a check-up.

Watch a video about the menstrual cycle.

What should you use when your periods start?

To be prepared for your first period, keep sanitary pads (sometimes called sanitary towels) or tampons at home, and carry some in your bag.

Sanitary pads line your underwear to soak up the blood as it leaves your vagina. Tampons are inserted inside the vagina to soak up the blood before it leaves the vagina. Tampons have a string that hangs outside the vagina, and you pull this to remove the tampon.

Don't flush sanitary pads or tampons down the toilet. Wrap them in paper and put them in the bin. Most women’s toilets have special bins for sanitary products.

There are different kinds of pads and tampons for light, medium and heavy blood flow. Use whatever you find most comfortable. Try different kinds until you find one that suits you. You might need to use different kinds at various points during your period. You need to change your pad or tampon several times a day.

You'll find instructions in the packet on how to use them. Sanitary pads and tampons are available in pharmacies, supermarkets, and some newsagents and petrol stations.

There's a life-threatening infection called Toxic Shock Syndrome (TSS), which affects around 20 people in the UK (men and women) every year. It’s not known why, but a lot of these cases occur in women who are wearing tampons, particularly highly absorbent ('heavy') ones. Find out more about TSS.

If you're worried about anything to do with periods or want more information, talk to an older woman, such as your mum, big sister, the school nurse or a teacher. Your doctor or local contraception or young people’s clinic can also help. Find sexual health services near you.

Is my period normal?

Don’t worry if your periods aren't the same as your friends’ periods. Every girl is different. Bleeding can last up to eight days, although it usually lasts about five days. The bleeding is heaviest during the first two days.

During your period, your blood flow may seem heavy, but the actual amount of blood is equivalent to between five and 12 teaspoons. However, you may have periods that are heavier than normal. This is known as menorrhagia, and there's medication to treat it, so talk to your doctor if you’re worried. Find out more about heavy periods. You can also take the heavy periods self-assessment to see if your periods are heavy.

The average length of the menstrual cycle (from the first day of your period until the day before your next period) is 28 days, although anywhere between 24 and 35 days is common.

Your hormone cycle may affect you physically and emotionally. Some women don’t have any symptoms, but on the days leading up to your period you may have symptoms of premenstrual syndrome. These include:

• headaches
• bloating
• irritability 
• backache 
• feeling depressed
• a general feeling of being upset or emotional
• difficulty sleeping
• difficulty concentrating
• breast tenderness
• some weight gain (up to 1kg)

Once your period has started, these symptoms usually improve. When your period has ended they disappear.

Periods can sometimes be painful. The precise cause of painful periods is unknown, but you may feel pain in your abdomen, back or vagina. It usually starts shortly before your period begins, and lasts for a few days. Painkillers can help. Find out more about treating painful periods.

What if my period is late?

If you're worried about your period, visit your doctor or a local community contraceptive or young persons clinic (call the sexual health helpline on 0300 123 7123 for details). Girls' periods can be irregular for many different reasons, including stress.

Another reason for a late period is pregnancy. If you've had sex without using contraception and your period is late, take a pregnancy test as soon as possible. You can get a test kit from your local doctor, contraceptive clinic or young person’s clinic. Find sexual health services near you. You can also do a pregnancy test yourself, using a test kit bought at a pharmacy or supermarket. 

Are my breasts too small?

No. Every woman is different and everyone’s body develops at its own rate. Don’t worry about what size is ‘normal’.

How do I know if I have breast cancer?

It’s unusual for teenagers to get breast cancer. Lumps, bumps and changes to the breast are common, and most of them are benign (non-cancerous).

There's no set method of checking your breasts, but get to know what they look and feel like so that you'll notice any changes. However, it’s normal for your breasts to change in size or become more tender during your menstrual cycle.

When must I have a cervical screening test?

A cervical screening test (sometimes called a smear) is a test where cells are taken from a woman’s cervix (located above the vagina) to check for changes that could lead to cervical cancer. Cervical cancer can be prevented if it's detected early through cervical screening.

In England, cervical screening tests are offered to women from age 25 upwards, every three to five years. You should have them whether you're straight, gay or bisexual. Women who have sex with women need to have cervical screening as well as women who have sex with men.

What is the hymen?

The hymen is a very thin piece of skin that stretches across the vagina, just inside the woman’s body. Every girl is born with a hymen, but it can break when using tampons, playing sport, or doing other activities, including having sex.

Do you put on weight when you're on the Pill?

No, there's no evidence that the contraceptive pill causes weight gain. Some girls and women put on weight while they're taking the Pill, but so do girls and women who aren't taking it.

If you’ve got any questions about the Pill or any other methods of contraception, such as the injection, implant or patch, go to a GP, local contraceptive clinic or young person’s service (call 0800 567 123). Find sexual health services near you. 

You can get free and confidential advice about sex, contraception and abortion even if you're under 16.

Can you get pregnant if you have sex during your period?

Yes. A girl can get pregnant if she has sex with a boy, at any time during her menstrual cycle, and can get pregnant the first time she has sex.

That’s why you should always use contraception. There are lots of different methods, including: 

• contraceptive cap
• combined pill
• condoms
• contraceptive implant
• contraceptive injection
• contraceptive patch
• diaphragms
• female condoms
• intrauterine device (IUD)
• Mirena (intrauterine system or IUS)
• natural family planning
• progestogen-only pill (mini-pill)
• vaginal ring

Only condoms help to protect you against STIs and pregnancy, so use condoms as well as your chosen method of contraception every time you have sex.

What is the clitoris?

The clitoris is a small soft bump in front of the entrance to the vagina. It's very sensitive, and touching and stimulating it can give strong feelings of sexual pleasure. This is how most girls masturbate. Most girls and women need the clitoris to be stimulated in order to have an orgasm during sex.

Find out 15 things you should know about sex.

Menstrual cycle: animation

This animation explains in detail how the menstrual cycle works.

Page last reviewed: 28/09/2013

Next review due: 28/09/2015

 

Boys' bodies Q&A

Puberty can be a confusing time because your body and your feelings are changing as you grow up. Here are answers to some of the questions that boys often ask about their bodies.

Click on the questions to go directly to the answer.

• What age do you go through puberty? 
• What's the average penis size? 
• What is circumcision? 
• I have spots on my penis and it itches. Is this normal? 
• Is it normal for my penis to smell fishy and have white bits behind the tip?
• What is sperm? 
• Is it normal to get an erection when you wake up in the morning? 
• Is it normal for one testicle to hang lower than the other? 
• How do I know if I have testicular cancer? 
• What is premature ejaculation? 
• Can you pee while having sex? 
• Why is it harder to ejaculate when you have sex a second time soon after the first? 

At what age do you go through puberty?

Puberty describes all the physical changes that children go through as they grow into adults. Most people start to notice changes at around 11 years old, but there's no right or wrong time to start puberty. It might be sooner or it might be later, and this is normal.

Read more on boys and puberty.

What's the average penis size?

Penis size varies from man to man, in the same way that everyone is a different height, weight and build. Most men's penises are somewhere around 9cm (3.75in) long when they’re not erect, but it’s normal for them to be shorter or longer than this. Some things can make your penis temporarily smaller, such as swimming or being cold.

Most penises are roughly the same size when they’re hard, between about 15 and 18cm (6-7in) long. You can’t make your penis larger or smaller with exercises or medication. Find out more about penis size.

What is circumcision?

Circumcision is an operation to remove the piece of skin (the foreskin) that covers the tip of the penis. In the UK, it's usually done for religious reasons, and is most common in the Jewish and Muslim communities. If you have been circumcised, it's nothing to worry about. It won’t affect your ability to have sex. 

Female genital mutilation (also called female circumcision) is illegal in the UK. It involves cutting off some or all of a girl’s external genitals, such as the labia and clitoris.

I have spots on my penis and it itches. Is this normal?

If you've recently had sex without using a condom you may have picked up a sexually transmitted infection (STI). Visit a sexual health or genitourinary medicine (GUM) clinic, GP, nurse, young people’s clinic or a community contraceptive clinic. Find a sexual health clinic near you.

Lots of boys have normal lumps and bumps on their penis, and spots can also be caused by an allergy or irritation. But if you're worried, seek advice from a doctor or clinic. Medical people see problems like this every day, so there's nothing to be embarrassed about.

Is it normal for my penis to smell fishy and have white bits behind the tip?

This can happen naturally from time to time. To prevent it happening, wash gently behind the foreskin if you have one (men who have been circumcised don’t have a foreskin) when you bath or shower. Use water, or water and a mild soap. Find out more about washing your penis.

If you're washing carefully and the symptoms don't go away, and you've had sex without a condom, you may have an STI. See a doctor, or visit a sexual health or genitourinary medicine (GUM) clinic, young people’s sexual health or a community contraceptive clinic. Find a sexual health clinic near you.

What is sperm?

Sperm is produced in the testicles (balls) and released in fluid called semen during sexual activity. Every time a man ejaculates (comes) he can produce more than 100 million sperm. But it only takes one sperm to get a girl pregnant, and that can happen before the boy ejaculates. This is because the fluid that comes out of the tip of his penis before he ejaculates (called pre-ejaculatory fluid) can contain sperm.

If you're having sex with a girl, always use contraception and condoms to prevent both pregnancy and STIs. Talk to your partner about what contraception she's using, and make sure that you use condoms too.

If you’re having sex with a boy, always use condoms to stop yourself getting an STI or passing one on.

Is it normal to get an erection when you wake up in the morning?

Yes, most boys have an erection when they wake up in the morning, and they can get one when they're not expecting it during the day, even when they’re not sexually excited. This is a normal part of sexual development and growing up.

Is it normal for one testicle to hang lower than the other?

Yes, this is normal and nothing to worry about. One theory is that it stops your testicles banging together when you run.

How do I know if I have testicular cancer?

Check your testicles every month by gently rolling them, one at a time, between your thumb and fingers to feel for any unusual lumps or bumps. You’ll feel a hard ridge on the upper back of each ball. This is the epididymis, where sperm is stored, and it’s normal to feel it here.

If you feel any lumps, it probably isn’t testicular cancer, but get it checked by a doctor. Other warning signs include:

• one ball growing larger or heavier than the other 
• an ache in your balls 
• bleeding from your penis

If you notice any of these, see your doctor. If caught early, testicular cancer can usually be treated successfully.

What is premature ejaculation?

This is when a boy or man ejaculates (comes) too quickly during sex. This is fairly common, especially among younger men, and can be due to nerves or over-excitement. Some people don’t worry about it, and some find that using a condom can help to delay ejaculation. Find out more about premature ejaculation.

If it bothers you, see your local doctor, nurse, or visit a sexual health or genitourinary medicine (GUM) clinic, young people’s clinic or community contraceptive clinic. These places will give you free and confidential advice whatever your age, even if you're under 16. Find a GP or sexual health clinic near you.

Can you pee while having sex?

No. During sex, a valve shuts the outlet tube from your bladder so that only sperm can pass through the tube (urethra), which you use to pee.

Why is it harder to ejaculate when you have sex a second time soon after the first?

If you have sex a second time straight after the first, it can take longer for you to reach orgasm (come). This is normal. If you're worried about this, take a longer break after sex before you start again. Whether it's the first, second or tenth time you've had sex that day, always use a new condom to protect against pregnancy and STIs.

Page last reviewed: 26/09/2013

Next review due: 26/09/2015

 Source: NHS Choices, UK