 Hello, Psych2Go viewers. I'm Michelle Rivas, host of Psychology Roundtable. Our amazing guest for today's live stream is Dr. Simi, who is a board-certified family medicine doctor. Dr. Simi is known for her valuable and educational content on women's health, where she has amassed a following of over 2.4 million individuals worldwide. Welcome, Dr. Simi. Thank you so much for joining us today. Thank you. Thank you. It's a pleasure. I'm so pleased to be here. I'm excited. I am too. I'm so excited as well. And so, can you tell us a little bit about yourself and your background? Yeah, of course. So I'm a GP, which is a board-certified family medicine physician. And I did my medical school training at Imperial College in London. And after that, when you finished medical school, you go into specialist training. And I actually initially went on the surgical path. So I was doing specialty training as a surgeon. Wow. Yes. So that was initially my path, my career path. But somewhere along the way, along that sort of halfway through, I decided that, you know what, I'm going to pivot on my career pathway and I'm going to become a GP. So that meant that I then had to come out of that and go and do general practice training. So now I'm a board-certified family medicine physician. So within kind of general practice, my areas of specialist interest that I, you know, really passionate about is skin health and women's health. So I've then gone to do further postgraduate training and get postgraduate qualifications in skin health, dermatology, and also sexual health and reproductive health, which is what we're going to be talking about today. Yeah. Thank you so much for that. Because women's health, I feel like is often overlooked. Like we talk about health, like sort of like it's an umbrella term, but I feel like men's health and women's health, it should be kind of separate. We should have like people who specialize in men or in women's. That's so true. Yeah, that's so true. I have to agree with you there. I think that women's health at the moment is starting to gain a lot more traction and a lot more kind of recognition. But traditionally, it's been maybe neglected and a lot of research is kind of focused on men and the response of men. So now we're having a moment where actually there's a lot more awareness around women's health and it's starting to gain a lot more recognition and a lot more traction. So it's quite an exciting space to be in at the moment. That's amazing. You're helping it, but you're helping the movement by bringing traction and advocating for it. So thank you so much for that. And so first I wanted to discuss women's sexual health and the different disorders that cause painful sex. Dr. Simi, what causes some women to experience pain during intercourse and can you explain the different disorders that cause it such as vaginimas or endometriosis just to name a few? Yeah, of course. So there are lots of different causes of painful sex. But first of all, I think if I just go back a little bit and talk about female sexual dysfunction, because I think that there is a lot more information out there about male sexual dysfunction. And some people don't realize that actually female sexual dysfunction is a thing and painful sex can be part of that female sexual dysfunction spectrum, if you like. So sexual dysfunction in general is just sort of women that are having problems related to sex, right? And within that there are several categories. So for example, previously it was sort of more, what shall I say, black and white. You sort of had painful sex in terms of vaginismus, which I will talk about in a second. And then you had painful sex in terms of dysparunia. But female sexual dysfunction is actually listed in the Diagnostic and Statistical Manual of Mental Disorders. And now they've created sort of three categories of sexual dysfunction. So those, again, before I answer the question, I kind of just want the audience to understand a little bit of the psyche that's going on with this. So if we think about the female sexual response, you have, for example, the desire phase, the interest in sex, right? So are you actually feeling like you want to have sex? What's your libido like? Then you have the arousal phase, which is the kind of anticipation of sex. And then you have the, you know, you have orgasm, and then you have resolution. And each of those stages, something can go wrong with that. And that's where you get the female sexual dysfunction coming through. So there could be a problem with interest. There could be a problem with low desire, for example. There could be a problem with orgasm. There could be a problem with penetration. And the problems with penetrations are the ones that are giving you pain during sex. Yeah, so that vaginismus would be classed as one of those. And that's, I know, something that you're quite keen to talk about today as well. Yes, yes, yes, vaginismus because a lot of women struggle with it. And they're unfortunately, especially just from what I've read online and research, a lot of women who suffer from vaginismus unfortunately are shamed by their partners. Can you explain to our audience members what vaginismus is? Yes, of course. I think you're right. There are, there is a lot of shame attached with vaginismus. And even from the women themselves, I feel kind of ashamed. Like, why is this going on? Is there something wrong with me? You know, why am I, you know, this, why am I friends not feeling like this? But essentially, vaginismus is a condition where you get involuntary tightening of the muscles that are surrounding the vagina, right? So this kind of closes the vagina down and it makes penetration difficult or painful or sometimes impossible. Okay, and you'll usually present in the way of, there might be some girls, for example, that realize that they've never been able to use a tampon. They just can't insert the tampon. Oh, it's that severe. Yes. And there are other cases, for example, where it can happen with different types of penetration. So for example, a finger or a tampon or a penis or even during a gynecological examination, where we use the speculum, you might find that the doctor can't pass the speculum. So this can be the ways in which vaginismus can present. And it's basically think of it as the body's automatic reaction to the fear of vaginal penetration. So there's a huge element to it whereby there is this absolute fear of penetration and the muscles around the vagina are then tightening to prevent penetration. Go ahead, sorry. It can really, really be quite distressing for the woman and also for her partner as well, actually. And is it completely psychological or is it more, could it be either one like just physical, like some people just have a vagina that, you know, it can't be penetrated or is it something that is psychological that needs like maybe a mental health treatment? So I wish it was that simple to categorize. Actually, it can be complex interplay, but the main component is psychological. So there's a huge psychological component to it. And you can think of it as a psychological condition that then manifests itself in a physical way. So, I mean, there are some physical causes as well. So any, if we're talking about physical causes, for example, any condition which causes pain during sex can lead to that anticipation in the woman where she's thinking, oh my gosh, it's going to be so painful and then cause these muscles to contract, right, even vaginismus. But usually there are sort of psychological aspects that kind of present as risk factors for getting vaginismus, right? So, for example, we can take previous traumatic experience. So that could be trauma during the previous childbirth. It could be a traumatic first sexual experience. It could be a traumatic medical examination. So if someone's had something, if a woman has had that happen to her in the past, this can affect her body's response to future attempts at penetration, right? Because she's kind of thinking of this traumatic event that's happened and then you're getting that reflex almost contraction of the muscles around the vagina because it's really not under the woman's control. She can't control it. Thank you for bringing that up. You mentioned that it could also be caused by trauma such as sexual assault or abuse as a child or something similar to that. So that's extremely difficult to hear because a lot of people, they think that there's something wrong with them when in reality it could be caused by just a really bad sexual encounter that they had or a rape or violation. So that's so true. And that's where I think it's important that we understand that if you suffer from vaginismus, if you're experiencing vaginismus, it's not your fault, right? It's not necessarily that you are doing anything wrong or that there's something wrong with you. Sometimes it's actually something that's quite subconscious and you have to do a lot of digging to try to get to the bottom of why is it that this is happening. And this is why it's such an interesting topic to talk about because there's a complex interplay because there are other things that can affect it psychologically as well. So for example, if there are problems within the relationship, if there's a lack of intimacy or trust between the partners, this can manifest as vaginismus. So it's not just to do with sexual abuse or traumatic sexual experiences, like you said. But I do agree with it. It's really important that women understand that this is not something that they are to blame for and that there is help out there. And the more if a woman is experiencing that, the more she gets shamed by her partner, I feel like it would make it worse, right? Like it's not going to open up the pelvic walls. That's right. So you can end up in a cycle whereby there's this shame and then actually now you're feeling more anxious and more worried. And then the vaginismus is sort of getting worse if you like. It's even more difficult to overcome. So certainly it can become a cycle where it can be difficult to break. But fear is quite a big component of it. So it might even be, for example, fear of pregnancy or fear of getting an STI, right? Or fear of anticipated pain. So it might be that you haven't even had any penetration, but just the thought of thinking, oh, this is going to be painful. That can also be a risk factor for getting vaginismus. And then, like I said, it's so complicated because there are other things as well. So if I think about women that have issues or women that have concerns, body image concerns, right? So maybe they're like, oh, I don't know. Maybe he'll think my vagina's too small or maybe my labia don't look right. Maybe one's bigger than the other. Maybe it's not the right color. Or maybe there's an odour. And all of these thoughts really play into this kind of psyche and this fear of being intimate. And this can also predispose to vaginismus. Do you think that this is due to a lack of education around sex in general, but especially women's health? Because I think that some of these, this could be preventable if we actually had this in schools, right? If we actually talked about it, but we stigmatized sex so much. I think that poor sex education is probably a factor but I wouldn't say that it's a cause because not everybody that has poor sex education gets vaginismus, right? But there are kind of the evidence shows that having poor sex education can feed into it because not understanding your body, not knowing how your sexual organs work, not knowing what your genitals look like or feel like or being scared to look at them and not being told much about how they work. And if there's this mystery surrounding genitalia and female sexual health, it can lead to this anxiety and fear of penetration later on. So definitely I think that there is something to be said about improving sex education for women, for girls, for boys as well, to remove the mystery that's around it so that women can feel more comfortable. And the other thing is actually religious and cultural beliefs can also play into it. So if you are part of a culture where women's sexuality is kind of repressed and you're not allowed to maybe explore your sexuality or maybe it's seen as being shameful to kind of explore that, that can also be a risk factor for vaginismus too. And with vaginismus, is it like temporary or is it permanent? That's another thing. A lot of women who get it, they might believe that it's like permanent. There's no cure for it. Yeah, so that's a good question. So there are different things that you can try in terms of treating it. So there's a whole host of different options actually. So it's not something that I would say once you have it, you have it for life. I think that you can access different types of treatments and different ways of managing it which can be individualized. So it depends on the individual because we've mainly kind of focused on the psychological aspects of vaginismus at the moment because that's the main component. But there are sometimes physical causes of why someone might have vaginismus and they can be, you know, probably dealt with a little bit easier than the psychological aspects. But yeah, so it's a condition that there is help and there are treatments that can be quite effective. So I would say to anyone who's experiencing that don't despair, you know, just educate yourself as much as you can about it and also speak to your doctor. So this is a situation where women would be coming to see me as their GP, you know, to say, look, this is what's happening. We would go through the history and we would, you know, I'd make the diagnosis of vaginismus and then we're looking at, okay, in this woman, what is the likely cause and how can we kind of manage that? Yeah, because it could be, like you said, it's so broad, it could literally be anything and so going to a doctor and seeking treatment, not trying to fix it yourself is the best option. Definitely. I think, I mean, if people that are listening to this are probably already, you know, step ahead because they're educating themselves about it. So there is that aspect of what you can do for yourself. The education part, I think, is really important. Yes, no, absolutely. And I was going to ask, how can these sexual disorders or problems that women experience impact their relationships? So, the impact is huge. I really think that it can be underestimated in women and I think certainly in my experience, at my practice, I actually consult with more men with female sexual dysfunction than I do women. And I don't think that's because women aren't experiencing it. I think that they are less likely to come forward, at least in my experience, right? Less likely to come forward. And also more likely to write it off as, oh, it's probably normal. Oh, maybe it's just because, you know, I've been with my partner for a long time. Oh, maybe it's just because, you know, I'm not feeling myself. I'm feeling down. Oh, maybe it's because I've just given birth. Or maybe it's because, you know, they're more likely to explain it. Well, maybe it's because I'm getting older or perhaps I'm approaching menopause. They're more likely to explain it away and therefore just kind of sit with it and not seek the help. But the impact can be, it can affect the quality of life, right? So being able to have a fulfilling sexual, you know, fulfilling sex life. Also it can impact relationships. It can impact the intimacy, the trust between partners. It can impact being able to start a family, right? If you can't have vaginal penetration, it would be very difficult to start a family. And then also it can actually cause anxiety, further anxiety and depression. And it becomes a little bit of a chicken-and-egg situation, right? Which comes first? So is it that the woman's anxious and this is causing the vaginismus? Or is it that having vaginismus is now causing the anxiety and the depression? It can be hard to tease out which comes first? No, definitely. It can be because... So it's like, what is the symptom? Is the vaginimus causing me to have depression or is the depression causing the vaginimus, right? Exactly. And it can actually, you know, be both. And I think the other thing is that it has... It can have significant impact on health, right? Because as women, we are encouraged to have cervical screening, right? I think we call it a smear test in the UK. I think you call it a PAP test. So if, you know, a woman can't have vaginal penetration, even with a speculum, that means that she's unable to have her screening test, her cervical screening test, her PAP test, which is actually a really important part of, you know, female health. And so what advice do you give women who are experiencing painful sex and who don't know what to do? What are some strategies that you can share with our audience? So I think the first thing, as I said before, is just understanding that it's not that you are doing anything wrong. So don't blame yourself and also know that there is help out there. I think I would start off with sort of simple things. So education is so key. So when I'm talking about education, I'm not just talking about knowing what vaginismus is, but also education around your anatomy, right? Your intimate anatomy. What are the different parts called? What are the female sexual organs? What are the female genitalia? A lot of women still refer to their vulva as their vagina, right? And sort of learn later on that actually know it's the hole that's the vagina and everything around that is the vulva. So understanding the terms, being comfortable using them, all helps to kind of remove that mystery and maybe some of that fear that might surround, you know, the vagina and sex, which can then impact on vaginismus. So that's the first thing that I would say is the education. Oh, yeah. Just go ahead. Sorry. I wanted to mention that I think that sometimes the psychological component of it also comes from maybe, unfortunately, being with someone you can't trust and the wrong person. And if it may be with someone else, you would possibly not have this problem, but you're with someone who maybe shames you. You don't trust them. They're not nurturing. They're not loving. So you're in a situation where like, even though you're telling yourself to have the sex, it's just not going to happen because your body, it's like your body feels it before you do. So you're absolutely right, actually. So there are some women who have vaginismus with one partner, but not another. So that's exactly describing what you are saying. And also it's such a complex condition because it's not absolute. It's not always absolute. So you can have a woman that has vaginismus with, let's say a penis with having penetrative sex, right? But not with a finger or with using tampons. So it's like a spectrum. And I completely agree with what you're saying. It can be to do with the level of trust that's within the relationship. And then speaking of trust, rather than shaming or getting angry with our partner, how can we support them if they're going through a sexual disorder or experiencing painful sex? So I'm going to come onto that in just a second because I don't think I fully answered the question you asked me before about how we can sort of help ourselves as well. But what I was going to say is because there is this huge psychological component to it, it's really important to kind of try to address that. And sometimes that might mean seeking therapy, right? Talking therapy. So it could be, for example, going to a psychosexual clinic where they can kind of explore more of the underlying psyche of what's going on and why this might be happening. It could be doing some CBT, getting some counselling. So there's a lot of work that can be done in terms of the psychological aspect. And also this is the part where partners can come along because it's often quite helpful to have the partner there if the woman wants to because then you're able to explore the dynamics of what's going on in the relationship as well to see if that could be a cause. It might not be. But there are also other things that can be done in terms of when the partners are being intimate. So for example, I talked about some of the physical causes of vaginismus, right? Lack of lubrication, for example, because of fear or because of a condition that's going on with the vagina. So sometimes the advice could be like, you know what? As a couple together, maybe spend more time on foreplay trying to increase the lubrication. There are vaginal lubricants that you can use as well. So these are the things that people can do to help themselves and the ways in which partner can support as well. Oh, that's perfect. It's 2-in-1, right? Okay. So that brings me to our audience segment where our amazing experts answer your viewer questions. But before we do that, we're doing a giveaway. Everyone who subscribes to our new channel will be entered for a chance to win a merch bundle, a plushie, a keychain, and a book. And so that is the link. You'll be entered right away when you subscribe to our new channel. It's called Pod to Go and we have the same types of conversations, just like these on the new channel. It's an extension of Psych2Go. But please, please, please subscribe. There'll also be a link in the description and in the comments. Okay, so now that we got that out of the way, let's start the questions. Are you ready, Dr. Sidney? Yeah, can I just add something else? Because there are a couple of options for managing vaginismus as well that I didn't get to talk about. So just quickly, there are vaginal dilators, which can be used under the instruction of a doctor or a therapist. And these are basically, they look almost like plastic tampons and they come in graduated sizes so they gradually get thicker and thicker. And these can be used as sort of exercises to help the vagina kind of get used to being penetrated. So these can be quite helpful. And there are also some women who have found treatment with Botox in the vagina helpful because it helps to relax the muscles that are around the vagina enough to allow penetration. Although the effects of Botox are temporary so it does wear off, but sometimes it could be enough to kind of just break that cycle of vaginismus to allow penetration. Thank you for that, Dr. Simi. That's really interesting. There's just so much we don't know even though like I'm a woman I should know some of these things, right? But the education just isn't there. And so our first question is from Mary. She asked Dr. Mary, I mean, Dr. Simi, I have a boyfriend and we have tried many times to have sex, but it couldn't happen. I feel scared and I don't allow him when he gets closer to me. And it just ends in him yelling at me. I cannot even insert a finger in my vagina. Please tell me what to do. I'm afraid that I will never be able to have sex. Thank you. I'm sorry, Mary. You don't deserve to be yelled at. So I think first of all, Mary, I would say that it's really brave of you to be able to come on here and kind of share that kind of personal story because it's something that's quite difficult to do. And I'm really sorry that you are experiencing such a difficult time. But I think the first thing that I want you to know is that it's not your fault. And the fact that you're already on this live listening to this, that's a great first step because you are educating yourself about what could be wrong and how you can go about kind of seeking help for that. So even though I can't give kind of direct medical advice, right, to individuals because I'm not your physician, I don't have all of the information about you that would be necessary to kind of help come to a diagnosis, I think there are some general things that I would advise. So first of all, maybe trying, what I advise women when they're in this situation is to talk to their partners and try to help them to understand even something like showing them this live stream, for example, of trying to just, that education part, right? It's the education part. And perhaps if you are feeling comfortable enough, I would definitely say, well, actually, let me go back one step. What I would advise is also to see your own doctor because what you want to do is have a detailed discussion with your doctor about this and your doctor will know enough about you and ask the right questions to be able to come to a diagnosis. Is this vaginismus or is this something else? And it's likely that your doctor would examine you. So because if I had a patient in your situation that came to me, I would be wanting to take this history, the story, how long it's been going on, what are the causes, you know, what is sex painful, all of these other conditions and then I'd be wanting to do a physical examination, if possible, before diagnosing. And I think once your doctor has had an opportunity to look at all of that, they would then be able to give you specific advice to your situation. So that's how I would advise women in general to go. And if women feel comfortable enough to take their partners along to these conversations, that can also be quite helpful. Or you might decide that actually you want to go to the initial consultation yourself and perhaps at a later stage bring your partner along. That's an idea so that it's like, so they understand what's going on because sometimes they don't know. And if they understood, it could make them more empathetic towards the situation. So thank you for that, Dr. Simi. And then enter pricing asked, does the pain from vaginimas make it more difficult for a female person to, for a female to achieve orgasm? Oh, so that's a really good question. So it's a myth that women who have vaginismus can't orgasm, right? Because they can still have fulfilling sex lives. They can still have orgasm from clitoral stimulation, from oral stimulation, and from other types of foreplay, right? But the pain can be a distraction. So it's not absolute. It doesn't mean that if you have vaginismus that you can't achieve an orgasm because there are other ways in which orgasm can be achieved. And plenty of women actually experience, you know, fulfilling orgasms despite the fact that they have vaginismus. Thank you for that. And then Mia asked, I have an issue with vaginal discharge. It happens all the time. And I asked my doctor, she said it's related to arousal, but I'm not sure. I'm tired all the time and I wear tampons on a daily basis. So Dr. Simi, did you want to answer that? Yeah, it's always difficult. I think I can give general advice in terms of, well, not general advice. I can give education around this, but I can't give specific advice because I don't know individual circumstances. But there are different types of vaginal discharge right there. There is physiological discharge, which is the discharge that you would expect, the normal discharge that you would expect, especially in women that have not yet reached menopause. And depending on where you are in your cycle, that discharge can vary, right, from being thicker, thinner, more copious or less copious. Now, if a woman is aroused, then what you're getting there is arousal fluid, right? So it's to do with the increased blood flow that's going to the genital area and that's actually increasing the amount of, it's preparing the vagina for penetration, right? So it's increasing the amount of fluid that's in there. And that's where you get that slippery, kind of thin watery fluid that's basically preparing the vagina for penetration to make it less painful. So it's difficult to advise on that because there are different types of discharge, right? You've got vaginal discharge, it can be physiological, so that means normal. You've got vaginal discharge that can be due to a problem in the vagina, for example, because of STIs or because of vaginal irritation or inflammation. And then you've got arousal fluid, which is the vagina being prepared for penetration. And can arousal can cause discharge? Arousal gives you that arousal fluid, which I guess some people would call discharge. So for example, they might notice that they have, you know, like a watery fluid in the knickers, right? So they'll describe that as discharge. I'll describe that as arousal fluid. But yeah, similar. They say niggers in lung. Yeah. They love that. You're laughing at that point. What do you say? That's so cute. What do you say? Pants or panties. I'd say knickers. I like that more. I think in the chat. And so Max asked if there's a muscle contraction. Is it possible that I could redirect into a UTI? How do you, how does it, if there's a muscle contraction? Yeah, they asked the questions kind of vague. I thought it was more medical. So I was like, I don't think, I don't even know like exactly what they're saying. But I thought maybe you would, if there's a muscle contraction, is it possible that I could redirect into a UTI? Maybe she means, maybe they mean a muscle contraction in their vagina. Okay. So usually that wouldn't happen, but sex can be associated with increased risk of getting a UTI. And that's just because it's to do with the anatomy and also the friction, right? So during sex, the kind of friction of the genitals rubbing, it can help to move the bacteria that normally live on the skin to the urethra, which is the P-hole, and it can make it easier for the bacteria to travel up the urethra and to cause a UTI. So that's where you classically will see that UTIs are often discussed in the context of sex. Thank you for that. And then Oneness Monster asked, does Vajranima say anything about a woman's nervous system dysregulation? Oh, that's such a good question. I think I'm going to have to go with yes and no. And the reason is because sex has to do with the woman's nervous system, the circulatory system, and also the hormonal system, right? It's an interplay of all of those. And then we're also then bringing into it all of these things that we've talked about. So fear, maybe anxiety, maybe disgust. And if you were to think of it in a way of, sometimes the fear is not necessarily, sometimes the reaction is not necessarily proportionate to the amount of danger, if you like, that the woman feels that she's in. So if you want to think of it as being dysregulatory in that sense, I would understand that. So this woman is, you know, the vaginismus is causing the muscles to contract because it's the body's reaction to, you know, this fear of penetration, but is there actually, is that fear founded or not? Or is it to do with past experiences? I don't know if I've explained that properly. Of course it's founded, but there is a lot of systems that are interplaying and it can be difficult to kind of separate them out. Like, oh, this is a nervous problem or this is a circulatory problem. This is all a complex interplay. Medicine is complex. That's why most of us don't do it. So yeah. That's what makes it so interesting, right? Yeah. So that's why you should always see treatment and speak to your doctor because every one situation is different. Definitely. Speak to your doctor. And I know that we've talked a lot about the psychology of it, but again, as with most things in medicine, it's not black and white. Sometimes I'll speak to women and I'll take the history and I can't find a psychological, you know, aspect. I can't find anything in the history that she's telling me that stands out like, you know, any past trauma or anything like that. And I also can't find a physical cause, but the vaginismus is there and it's real. Thank you for that. And then the next question is a really good one. Concert asked, I've experienced pain with penetration and arousal my whole life. I've been assaulted, but it was an issue before as well. Is it possible to be born with vaginomas? Why does it hurt to just be aroused? So that's a really good question. So vaginismus is sort of split into two types, right? So you have vaginismus that's always been there. So I wouldn't say that you're born with it, but some women find that they've never been able to insert a finger. They've never been able to use a tampon. They can't have gynecs and they can't have sex. So that's kind of lifelong. It's been there all along. And then you have vaginismus that develops secondary to an issue. So for example, they've been able to have penetrative sex, completely fine, no pain. And then something happens. And from then on, they start experiencing vaginismus. So you can have vaginismus that's been there all your life, but it's not, I wouldn't say something that you are born with, right? It's to do with this complex interplay of the psyche and the emotional aspects of sex or penetration of the vagina. And then our next question is, why, so Moonstar asked, why would I experience painless sex years after giving birth? I didn't have issues with pain beforehand. And when you answer this question, maybe you could also give like some advice or strategies for someone who's dealing with it, who's just given birth or, you know. Okay. So the question is why does she have painless sex? Why does she have pain with, no, no, why does she have pain with sex? Okay, right. Years after giving birth. Okay. I mean, it's a difficult one to answer because again, without having the full story of, you know, how long after giving birth did that pain start? Whether there are other aspects to that symptom, is it just pained with sex or is it actually pain and inability to penetrate as well? So it's very difficult. And also it also depends on age as well because there are certain conditions, for example, menopause, where it can start to be painful to have sex. Specifically with relation to pain after giving birth, initially it can be due to, you know, when you give birth and sometimes women have to have a cut and they appease your autonomy. And when that area gets healed, there's a little bit of a scar there. And that can be quite sensitive for a while after giving birth. So some women find that after giving birth, even when they feel that the stitches have kind of healed and everything looks okay, that they're still experiencing pain when they're trying to have sex. And sometimes that anticipation of sex can also reduce the arousal fluid, which means that the vagina's more dry, which is then going to make sex more painful, right? So there are different reasons as to why. I don't think that there is enough in there that I would want to kind of, you know, be giving specific advice. And again, I try really hard not to give specific advice because as doctors we can't do that unless people are our patients. But, you know, definitely education I'm happy to do. So I would say for something like that, it needs more information about when and what circumstances that that painful sex was coming along after childbirth. And then our last question is from Jax Jax Rose. She asks, how do you maintain a healthy, a healthy vulva or prevent thinning in front of the vulva skin that could lead to tearing above the clitoris? Is this a sign of premenopause? Okay. So how do you maintain a healthy vulva? Yes. What was your question? So how do you maintain a healthy vulva and prevent thinning in front of the vulva skin that could lead to tearing above the clitoris? Is this a sign of premenopause? I'll put it up. Okay. So I think it's, to me, it's almost like two questions in one. Yeah. I maintain a healthy vulva. So I'll talk about that first. So I think first of all is kind of focusing on vulval hygiene, you know, making sure that you are washing, keeping the area clean, making sure that it's nice and dry so that you're reducing your chances of having kind of vulval infections and things like that. It's also practicing safe sex that's going to reduce risks of, you know, having sexually transmitted infections which can cause vulval problems and also, for example, herpes, which can then cause painful sex. It's keeping up to date with your gynecology appointments, your smear test or PAP test, so that everything there is, you're checking that everything's healthy and that you're not going to run into problems or that if there are problems that they're detected early and that you can get help for it, you know. The question about the thinning of the vagina to do with menopause, that's really common. So you can get vulvovagina atrophy which is thinning out of the vaginal lining of the vaginal tissues and there are different ways that this can be treated including using lubricants and also estrogen creams on the vagina but that's something that you'd have to see a doctor about and they would go through what your options are for that. Thank you for that Dr. Simi and that concludes our audience segment and so my last question for you Dr. Simi is how can we make women's health more accessible since we do have a lot of pink taxes at least in the US on things like tampons on certain women's feminine hygiene products and a lot of treatment for endometriosis is really inaccessible. So what do you think we should do to make it more accessible for women because it's very important that we have access to this education and to these things? Yeah, I think it's talking about it. So making a noise showing that actually there is a need for women's health education that we are interested, that we want more information that we are engaged and that we want to learn about our bodies and I think the more noise we can make about that the less that we can be ignored. I've seen kind of huge strides already in terms of the information that's available on women's health and I think that we're kind of moving in the right direction and also I think not restricting women's health education to women, right? And then also need to learn about women's health and also support us and to kind of have these conversations with us removing the shame from the discussions. Yes, we want to talk about periods. Yes, we want to know what our genitals are called. We want to understand how they work. We want to be able to talk about sex. We want to be able to educate our girls and our boys and there's no shame in talking about it. It's not disgusting periods are not disgusting. So it's all of these messages that I think that we should embrace so that this information is more freely available to us and it can just help us to be healthier. Thank you for bringing that up because I do think that men need to understand women's education. I don't know if they should make it a requirement in the school curriculum. I don't know what they should do, but I do think that they should understand more because it will sort of like increase compassion and empathy around the issue. So thank you so much, Dr. Simi, for joining us today. This was an amazing conversation. We appreciate it so much. Thank you. Thank you. It's been lovely being here. Thank you for having me on. Of course, and thank you to our Psych2Go viewers and so you guys know we have a members only. We have two live streams on Thursday, a 30 minute one where we will answer all of your viewer questions and then a members only one. So please become a member. There's so many perks. Hopefully you guys can do that by Thursday and thank you guys so much. Have a great day. Bye-bye. Thank you. Bye.