80% of women will experience menopause symptoms. Dr Unnati Desai discusses some of the treatment options.

It’s stories like these that make you realise menopause symptoms can make life a living hell for some women. This is the story of Jane Lewis, the author of Me and My Menopausal Vagina:

“Hello, I’m Jane and I’m 52 years old. I live with my husband of 34 years, have three grown up daughters, a granddaughter, and two dogs: Bertie and Bonnie. I used to live a really active life but then something changed. 

I’m not quite sure the exact moment when things went so drastically downhill, but I do remember one day being at the cinema and suddenly realising that I couldn’t sit down. After only 20 minutes, I took myself to the back of the theatre and stood alone, swaying from side to side trying to calm the burning from my vulva and vagina. I haven’t been able to sit through a film since.

For seven years I’ve been suffering from vaginal atrophy and have tried pretty much everything out there to try to help me. I learnt so much from it that I decided to write a book [My Menopausal Vagina] to share my experiences so you don’t ever feel as alone as I did.“

Well, Jane is certainly not alone. I see many patients in Jane’s situation and the plethora of comments on pages dedicated to menopause on social media only reinforce just how difficult this process can be.  On those posts many women say they can’t find the information they need or get the support that need from their GP. Many also complain that they are only offered anti-depressants instead of HRT, as recommended in the NICE guidelines.

It’s true HRT still gets bad press. This has been the case since the 2002 Women’s Health Initiative first raised fears about a possible link to breast cancer. But it has since been widely recognised that the risk is much lower than previously thought and that the benefits of HRT may outweigh them when it comes to protection of the bones, heart and brain.

That’s why the UK guidelines recommend that the majority of women should be offered HRT as a first line treatment, unless there is a history breast, ovarian or endometrial cancer or there other risk factors such as liver disease, untreated high blood pressure or having had a blood clot.

HRT may include oestrogen, progesterone and a hormone that’s usually associated with men – testosterone. Woman do manufacture a small amount of testosterone but, like oestrogen, this too declines with age.

Oestrogen comes in tablets, topical gels and creams and pessary versions. The vaginal oestrogen gels or pessaries are often suitable for women who have had breast cancer as there is very little systemic absorption.

The topical versions have an advantage over oral versions as they bypass the liver and therefore have a lower overall risk profile.

There is also a progesterone coil (Mirena) that can be inserted into the uterus that can provide 5 years worth of steady supply. All women taking oestrogen who have a uterus will require some level of progesterone to help protect the womb.

Testosterone can come in a cream or lozenge.

So, let’s run through the four main sets of symptoms and what else can help in addition to HRT. Remember, you may not experience all of these menopause symptoms, and the ones you do experience may be to varying degrees in comparison to your friends or family members. This is because every woman’s menopause is unique.

The four broad groups of menopause symptoms

1. Bleeding changes: these can be lighter and less frequent periods, heavier periods, or an increase in the number of periods. In the case of the last two there can be a risk of developing anaemia (not having enough iron in your blood), so it’s important to eat well with an iron rich diet and also have regular blood tests to ensure the iron levels are sufficient. An iron supplement may be required. Progesterone, such as the coil, is often prescribed to help decrease the bleeding.

2. Vaso-motor: these include the the common ones that many women experience such as hot flushes and night sweats. Sleeping in a cool room and wearing layered clothes during the day can help with these symptoms, as can drinking less alcohol, smoking less, and exercising more.

There are also a number of drugs that are used to help control these including some anti-depressants, an anti-convulsant drug called gabapentin, and a blood pressure drug called Clonidine.

Some women say they see improvements with certain over-the-counter herbal supplements. Always tell your doctor if you are taking these as they may have interactions with certain medications.

3. Psycho-social: Common ones in this category include what’s often described as ‘brain fog’ which is an inability to focus, concentrate, or remember things.

There’s also irritability, tearfulness, low mood and anxiety. For many women these can cause significant problems at work as they appear forgetful and their productivity may drop.

For others a low libido is often cited as a common symptom, which can have far reaching effects on their relationships. This is where the testosterone may help as well.

Cognitive Behavioural Therapy (CBT) can sometimes help with these symptoms too.

Again a healthy lifestyle and activities that help de-stress like yoga can be beneficial.

4. Genitourinary symptoms: These include stress incontinence (peeing when you sneeze, laugh or jump), vaginal dryness, pain during or after sex, as well as frequent urinary tract infections or thrush infections. The vaginal dryness and an increase in infections often start 2-3 years after your last period.

Why? Well, the uterus, bladder and bowel are all oestrogen dependent (in fact we have oestrogen receptors in many parts of out body including the skin, breasts, brain and heart.)

As the oestrogen levels drop, tissue thickness in the pelvic region decreases too. The vaginal wall begins to to thin (vaginal atrophy) and the risk of prolapse increases, as does the leakage when we sneeze, jump or laugh. The lining will also become dryer and pain during or after sex can start> Because the mucosa is thinner and less well lubricated, the flora changes which can lead to increased urinary tract infections or cases of thrush.

Surgical mesh was one solution to these issues in the past but is not longer considered a suitable option due to the complications that arose from it.

That leaves HRT or non-invasive vaginal rejuvenation treatments like the O-shot (PRP) or laser, ultrasound or radio-frequency treatments that use heat to create micro-damage to walls of the vagina. These are novel or newer treatments that are starting to show some good results in many women – but it is early days and more evidence is needed to really prove their worth.

How do they work?

The heat causes micro-damage to the underlying layers of tissue. This in turn sparks a healing and tightening process that reduces vaginal laxity as well as improving blood supply and building collagen. The result is a tightening and uplifting that can decrease stress incontinence, improve lubrication and decrease pain during and after sex.

PRP or the O-Shot can also help by encouraging improved blood supply and collagen production. It can also help with a condition called Lichen Sclerosus, a long-term condition that causes itchy white plaques, often on the genitals.

A combination of these treatments can also be if appropriate.

What results can you expect? 

Improved tissue quality, thicker, plumper and better lubricated. And, because the area is better lubricated you can also expect a decrease in pain during or after sex and less infections as the micro-flora in the region will have a healthier environment.

New Drug – Senshio (Ospemifene)

There is also a new drug on the market called Senshio. It is an oestrogen receptor modulator which is recommended for women who have moderate to severe vaginal symptoms who aren’t suitable for HRT as they have a high risk of breast cancer or have had breast cancer, or those do not wish to take it.

The European Medical Agency (EMA) has approved ospemifene for the treatment of moderate to severe symptomatic vulvar and vaginal atrophy in post-menopausal women who are not candidates for local vaginal oestrogen therapy. It has also been approved by the FDA in America for women experiencing moderate to sever dyspareunia  (pain during sexual intercourse).

The EMA says “the active substance in Senshio, ospemifene, is a selective oestrogen receptor modulator (SERM). This means that it stimulates the receptor for oestrogen in some tissues in the body such as the vagina. By stimulating the oestrogen receptor in vaginal tissue, ospemifene helps to reverse symptoms of vulvovaginal atrophy. However, ospemifene does not stimulate oestrogen receptors in other tissues such as the breast and womb, where stimulation could cause hyperplasia (growth) of tissues which could lead to cancer.”

It is not available yet on the NHS and is only available in the UK on a private prescription.

Take home message

Our genital region ages just like the rest of our body, so it’s important to start looking after it earlier rather than later. The longer the symptoms of vaginal atrophy are ignored the worse they will get and the chances of seeing a significant improvement will be decreased.

Like anything else, prevention is the key.

You can find out more about Dr Unnati Desai by clicking here.

Looking for more evidence-based information on Menopause? Sign up to our Menopause Guide

Editor’s note: You can find Jane’s book here: 

https://www.mymenopausalvagina.co.uk/my-book