Dr Paula Briggs, Consultant in Sexual & Reproductive Health talks menopause. Specifically the less commonly known symptoms that can leave some women feeling helpless.
Oestrogen is a really important hormone for women. It is present in varying amounts during reproductive life - before the menopause. When women reach the menopause, usually around the age of 51, the ovaries stop producing oestrogen and this is what causes menopausal symptoms. Some of these symptoms are better recognised than others. These include hot flushes, night sweats, and difficulty sleeping (the evil twins!). Other less well recognised menopausal symptoms include mood changes and anxiety, which can impact on quality of life and ability to function in the workplace.
At Liverpool Women’s Hospital we have a vibrant menopause service. During the pandemic, we offered telephone appointments to patients waiting for both new and review appointments and for most women this worked well. We provide training, both for our own staff and for primary care clinicians working in Liverpool and surrounding areas.
The menopause team includes Kathie Cooke, Consultant nurse, Mr Richard Russell, Consultant Gynaecologist and me, Dr Paula Briggs, Consultant in Sexual & Reproductive Health. For the past 18 months we have collaborated with primary care in Liverpool and the surrounding areas through a free monthly education programme coordinated by Kathy Smith. We also work closely with the specialist pelvic floor physiotherapists, psychosexual therapists and the pharmacy department.
What I really wanted to talk about today is the other less commonly discussed menopausal symptoms including those affecting the urogenital tissues (vulva, vagina, urethra and bladder). Up to 80% of women suffer from the effect of lack of oestrogen on the tissue quality in these areas causing common symptoms such as vaginal itching, burning, pain with sexual intercourse and recurrent urinary tract infections (UTIs) and many of these women are reluctant to ask for help unless asked specifically about these symptoms.
There is a silent epidemic with affected women often missing the link between the symptoms they are experiencing and menopause which may have occurred several years earlier. Many affected women are unaware of the treatment and support available. This excerpt taken from a patient’s feedback highlights just how awful symptoms can be:
“I am 58 years old. In 2002 I had a full hysterectomy, removal of ovaries, and was started on HRT. Fifteen months later in 2004, I was diagnosed with breast cancer, had a lumpectomy, 5 weeks of radiotherapy, and was commenced on Arimidex for 5 years (this is a drug which blocks oestrogen). For 17 years, I managed menopausal symptoms – mild hot flushes, lack of sleep (averaging 2-3 hours a night) and having to work 12 and a half hour shifts struggling with lack of concentration, irritability, brain fog, and depression. Initially, I did not suffer with any urogenital problems and I just thought, “Who is going to help me? I’ve had breast cancer, I can’t have HRT, just get on with it”. And I did get on with it.
Fast forward to September 2020. I was busy working in the middle of the pandemic, and overnight my life changed. I woke up with really bad cystitis symptoms. I thought it was stress – how wrong was I. Six lots of oral antibiotics, a cystoscopy for query bladder cancer, one admission and stay in hospital for IV antibiotics, sixteen weekly bladder installations – these are given through a catheter inserted into an already red, sore and swollen urethra. My provisional diagnosis was interstitial cystitis and I have been told I am the only patient who has not been completely cured with the number of instillations I have had. I was referred to Gynaecology, but was told “I doubt there is anything they can give you, either topical or oral, as you’ve had breast cancer”. I couldn’t go to work, walk, sit down or wear any underwear. I was in constant pain and irritation. I’d gone from a happy, healthy, active woman to a shell of myself. I was suicidal. The life I had before September 2020 no longer existed, and I no longer wanted to live like this anymore. It didn’t help being told to try to take your mind off it, busy yourself, make a cup of tea, join a gym.
I started to research myself about menopausal symptoms and breast cancer and found the menopause service at Liverpool Women’s Hospital. My appointment was last week and broke down during the consultation through sheer relief that I was listened to and told that I wasn’t the only woman to suffer from this condition, likely caused by lack of oestrogen due to menopause (and made worse due to the treatment required for my breast cancer). I have started on medication and am hopeful, and remain positive, that it will help. But even if it doesn’t, I know there are other medications out there. I can honestly say, this is worse than having breast cancer and a hysterectomy, both put together. I wouldn’t want any other woman to go through what I’ve been through, not knowing where to go for help. I am so very grateful.”
To help support these women, I am currently undertaking a research study Vaginal Health, What’s Normal –VAN, to investigate the most effective method of diagnosing the effect of lack of oestrogen on urogenital tissue quality. Supervision and support is provided by Professor Dharani Hapangama with additional support from the research department at Liverpool Women’s Hospital and sponsorship provided by the University of Liverpool.
We were delighted recruitment to the study for the initial assessment was very quick, with women keen to support research into this frequently ignored problem and also happy to be able to access some of the newer licensed treatments not yet available from their GP. We are also working closely with the breast services in Liverpool to try to prevent women like the patient quoted about from suffering to this extent.
Alongside the study we have some exciting possible research projects in development, one involving a new non-hormonal drug, which will be trialled specifically in women not eligible for hormone treatment, who are suffering from menopausal flushes and night sweats and one possibly researching the effect of vaginal laser therapy for women with urogenital symptoms who have had breast cancer and are either not suitable or who do not want to use hormonal treatments.