During my 20 years as a pharmacist, I saw a pattern. Women would walk in, bursting with urgent questions about their intimate health, yet clearly felt nervous, embarrassed or unsure of how to put their worries into words.

So five years ago I started posting regularly as the Fabulous Pharmacist on Instagram, encouraging women to ask anything about their intimate areas. And let’s not be coy – as that is half the problem – by intimate areas I mean vaginas and vulvas.

Not only is it my mission to inform on sexual and vaginal health, it is to crush any shame or embarrassment around our bodies.

It turns out there’s a vast but unmet need for no-nonsense, science-backed advice on these ‘unmentionables’, which is why I’ve written a book called Love Your Vulva, because if we can talk about our anatomy honestly and openly, it’s transformative for our health and wellbeing – not to mention for our relationships too.

For many, what happens ‘down below’ feels taboo – whether you’re 13, 53 or 73. But I particularly find as we reach the end of our 40s – I’m 45 – and hit perimenopause, physical changes can cause a lot of misery and confusion.

This impacts quality of life, yet millions of women feel too ashamed to ask for help – risking their health, happiness and even marriages (there’s a reason UK divorce rates peak for couples aged 45 to 49). So here’s my advice for overcoming common intimate challenges in midlife and beyond.

Don’t skip the cake!

The decline in oestrogen that starts in perimenopause – which comes for most women during their late 40s – can lead to changes in the vulva, vagina, urethra and bladder.

GSM (the drearily named Genitourinary Syndrome of Menopause) affects 80 per cent of women in some way. It makes the tissue of the vulva and vagina more thin and less elastic, which can cause vaginal dryness, itching and burning or pain during sex.

From my Fabulous Pharmacist online ‘confession’ box, where women write in anonymously, I’ve learned many no longer climax during sex. That’s like going to a party and skipping the cake – let’s be honest, nobody wants to do that!

Instead, plump for the magic cream

The good news is there are topical or vaginal oestrogen treatments that work miracles. They’re widely available on prescription – product names include Vagifem, Estriol and Imvaggis.

They can prevent the vulval and vaginal tissue from thinning, support its repair and plump up your clitoris. Yes, you read that right. Clitoral shrinkage is another symptom of GSM. You didn’t know? I think it’s fair to say we certainly would know if men’s penises were shrinking in midlife. But many women don’t realise it’s happening – or that this is why orgasms can become elusive.

One patient told me at 73 she hadn’t had sex in a decade. I sent her to the GP and after four months of vaginal oestrogen she was enjoying herself in bed with her husband again. He still sends me a Christmas card every year.

Keep up with your workouts

Do you, to your horror, leak when you laugh, sneeze or run – or even orgasm for that matter? That’s called Stress Urinary Incontinence.

Or maybe as you unlock your front door you feel a sudden uncontrollable urge to use the loo – and sometimes reach the bathroom too late? That’s Urge Urinary Incontinence.

Half of women in menopause and beyond experience at least one of the two thanks to a weakened pelvic floor, reduced bladder elasticity and increased vaginal dryness.

Putting up with incontinence has become normalised and that is completely unacceptable. You do have options, but I would suggest first seeing a specialist physiotherapist who can teach you pelvic floor exercises such as a visual technique where you ‘suck the spaghetti’. Lie with your knees bent. Imagine a piece of cooked spaghetti at your vagina entrance, and imagine sucking it up towards your belly button. Hold for ten seconds, relax. Repeat ten times. Then do ten quick pulses. Do three sets a day. For extra fun, practice during sex…

The ring of confidence

Weakened pelvic floor muscles can lead to prolapse (when the bladder, uterus or bowel drops into the vaginal canal). You might feel dragging, heaviness or a lump or even leak when exercising.

Allow me to introduce what my physiotherapist friend calls the ‘ring of confidence.’ It’s a pessary, a small silicone device that helps regain control, comfort and confidence – no surgery required.

A ring is simple to insert and usually fitted by a physiotherapist or gynaecologist after a gentle manual examination. There are other types of pessaries – all provide internal support and some help prevent leaking. Ring pessaries can even stay in place during sex – it may even add extra sensation, so enjoy!