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Managing hidden symptoms of the menopause

The very common intermediate menopausal symptoms, which can cause significant distress, are hugely under-reported and undertreated, despite effective and safe treatments being available. This article will address the problem of urogenital atrophy, focusing on physiology, symptoms and treatment

Heather Currie
MB BS FRCOG MRCGP MFFP
Associate Specialist Gynaecologist and Obstetrician
Dumfries and Galloway Royal Infirmary

The consequences of the menopause can be divided into categories: early, intermediate and long term. The early menopausal symptoms, such as hot flushes, night sweats, insomnia, joint aches and mood changes, are well known and often effectively treated. Similarly, long-term consequences of increasing risk of osteoporosis and cardiovascular disease are receiving more attention than in the past.

However, this is not true for the very common intermediate menopausal symptoms, which can cause significant distress, and are hugely under-reported and undertreated, despite effective and safe treatments being available. Women should be given the opportunity to discuss symptoms that often cause embarrassment and healthcare professionals should be more aware of the extent of the problem.

Vaginal atrophy
Physiology
Under the influence of oestrogen, the premenopausal vaginal epithelium is thick, elastic and supple. With a good blood supply, transudates from capillaries provide lubrication and moisture, and mucus production from glands adds to lubrication. Adequate glycogen within cells encourages colonisation of lactobacilli that produce lactic acid, maintaining an acidic pH of around 4, providing resistance against other micro-organisms.

Reduced oestrogen associated with the menopause leads to reduced blood supply and thereby less transudation, reduced mucus production, and dry, thin, fragile epithelium with reduced elasticity. Lack of glycogen within cells leads to less colonisation of lactobacilli, less lactic acid production and a raised pH of around 7, and increased susceptibility to colonisation with
pathogenic micro-organisms.

Timing
Classically, symptoms of urogenital atrophy are noticed two to three years after the menopause, or after stopping hormone replacement therapy (HRT); but in some women, changes are noticed earlier, often in the perimenopause when oestrogen levels are gradually falling. Symptoms can also present in premenopausal women, in situations of oestrogen deficiency, such as in women who are breastfeeding; on long-term Depo Provera; or in those women who are taking gonadotropin-releasing hormone (GnRH) analogues (often prescribed for endometriosis, for example).

Diagnosis
Diagnosis of vaginal atrophy is usually from the history of the presence of typical symptoms. Examination would reveal the vulva to lack plumpness, the vagina to appear pale and dry, and small petechiae may be present. The loss of elasticity leads to flattening of the vaginal walls – the loss of "wrinkles"! Some interest has been shown in measuring vaginal pH to aid diagnosis, although this is not routinely used.

Symptoms
Reduced lubrication during intercourse is often the first symptom and is usually self-treated with lubricants. Vaginal dryness is the most well-known symptom of vaginal atrophy, and this in itself can cause reduced sensation and discomfort during intercourse. The discomfort has been described as feeling like "broken glass" and "sandpaper"; thinning of the vaginal and vulval skin causes irritation and discomfort, even from gentle friction, such as rubbing on underwear. Increased sensitivity to infection can cause discharge (that may be smelly and distressing), irritation and soreness.

In some women, the epithelium may be so fragile that bleeding occurs. Of course, any postmenopausal bleeding should be investigated appropriately and not assumed to be due to atrophy. Symptoms tend to be worse in women who smoke, possibly due to a direct effect on vaginal epithelium and reduced bioavailability of oestrogen. Symptoms often lead to reduced libido and sometimes relationship problems.

Lower urinary tract atrophy
Oestrogen receptors are present in the bladder trigone, detrusor muscle and urethral sphincter and with oestrogen lack, these tissues very commonly atrophy. Resulting symptoms include dysuria (pain on urination), frequency, urgency, urge incontinence and nocturia (the need to get up and urinate during the night). Such symptoms may mimic cystitis and are often treated inappropriately with repeated courses
of antibiotics.

Pelvic floor atrophy
Support ligaments of the pelvic floor are oestrogen-sensitive, and lack of oestrogen leading to changes in collagen can contribute to bulging or ballooning of the vaginal walls, descent of the cervix and an uncomfortable dragging sensation. The urethra may become shortened, increasing the risk of urinary tract infection.

Lack of oestrogen can also contribute to stress incontinence. Although a large number of women (an estimated 70%) time the onset of stress incontinence to their menopause, factors other than lack of oestrogen are also implicated in the mechanism of stress incontinence.

Incidence of genitourinary atrophy
It has been estimated that 45% of menopausal women have signs and symptoms of vaginal atrophy and that by the age of 75, two thirds of women are affected.1

An online survey of 1,002 women (conducted by www.menopausematters.co.uk) showed that 54% of perimenopausal respondents and 63% of menopausal respondents had experienced vaginal symptoms such as dryness, irritation or discomfort during intercourse.

Of these women, 43% said that their symptoms were so severe that their sex lives were affected, with 42% admitting to making excuses to avoid having sex because of discomfort, yet 88% felt that it is important to continue an active sex life into old age. A total of 60% of respondents reported feeling less confident as a result of their symptoms; and 49% of women in the survey reported bladder symptoms.2

Extent of under-reporting and undertreating
It has previously been estimated that only 20–25% of women with symptoms of genitourinary atrophy seek help; and of these, only about a quarter receive treatment, despite some very effective treatments being available.

From the online survey, 80% of women with vaginal symptoms had not discussed their problem with a health professional and 61% of women with vaginal symptoms hide their symptoms from their partner. Only 36% of women with vaginal symptoms had used some form of treatment, of which only one third had had treatment from their doctor. Of the women with bladder symptoms, only 21% had discussed their symptoms with a doctor, and only 9% had been prescribed treatment.
 
Two percent had used over-the-counter preparations and 89% had not tried any treatment at all. In a further online survey in 2008 of 2,203 women, 38% of perimenopausal women and 56% of postmenopausal women reported vaginal dryness, with 78% of peri- and 87% of postmenopausal women believing it to be a factor in their loss of libido. Again, few had discussed this with a health professional, and even fewer were taking treatment.

Reasons for under-reporting and undertreatment
Many women continue to feel embarrassed and unable to discuss vaginal and bladder symptoms. Bladder problems are often associated with getting older, and to admit to bladder problems carries a stigma of old age. Women are often unaware that effective treatments are available.

As healthcare professionals, we may find it difficult discussing vaginal discomfort or sexual problems, and may not allow enough time to give women the opportunity to report their symptoms. We need to be more aware of the extent of the problem and ask appropriate questions to encourage discussion.

Management of genitourinary atrophy
Nonhormonal moisturisers, such as Replens (purified water), Yes, Senselle and Sylk (kiwi fruit extract) can be purchased over the counter, and Replens and Sylk can both now also be prescribed. These products can help to remedy vaginal dryness and reduce discomfort to some extent, although they are unlikely to help with bladder symptoms. As with many alternative therapies, they have been subjected to very few, if any, placebo-controlled trials. Systemic HRT often alleviates symptoms and is the appropriate treatment if systemic menopausal symptoms, such as hot flushes, night sweats, insomnia and joint aches are also present. However, it should be noted that about 10–25% of women taking systemic HRT still experience genitourinary atrophy and may benefit from vaginal oestrogen in addition.

Vaginal oestrogen has been shown to be extremely effective for treatment of vaginal atrophy in relieving symptoms by restoring the vaginal epithelium to the premenopausal state (see Table 1). When used to treat bladder symptoms, oestrogen has been shown to reduce urinary frequency, urgency and nocturia. Oestrogen alone may not be sufficient to treat stress incontinence but may help when used along with other strategies such as losing weight if indicated, reducing caffeine intake, encouraging regular (at least daily) pelvic floor exercises, and using specific therapies.

[[Table 1 meno]] 

Vaginal oestrogen is generally well tolerated. Skin irritation may occasionally occur with one type and, if so, a different preparation is worth trying.

Duration of treatment
There is much confusion around the safe duration of use of vaginal oestrogen. This is fuelled by the fact that some products only have a license for three to six months; yet longer term use is often advised. Concern has been expressed about the possible endometrial stimulation effect of longer duration vaginal oestrogen. Few studies have examined this effect but those available have shown no endometrial stimulation by using the vaginal tablet or ring for up to two years use at maintenance dose. Only Premarin vaginal cream was associated with endometrial stimulation, suggesting systemic absorption.

Currently, it is often advised that treatment should be stopped after varying intervals, but symptoms frequently return on stopping. From the evidence available, it seems reasonable to continue vaginal oestrogen (with the exception of Premarin cream) at the maintenance dose for longer than three months, and for the tablet and ring, for up to two years at least; and, in fact, Vagifem is now licensed to be used long term, for as long as treatment is required. If treatment is then stopped, it can later be restarted if symptoms recur. If the patient has had a hysterectomy, then there would not be any concern about any possible endometrial stimulation and so vaginal oestrogen could be continued for as long as is required.

Finally, because of negligible systemic absorption, vaginal oestrogen can often be used for troublesome symptoms when systemic HRT may be contraindicated.

Conclusion
Urogenital atrophy is a very common menopausal problem, the symptoms of which can cause significant distress and compromise sexual health and relationships. Despite very effective, safe treatments being available, the symptoms are hugely under-reported and undertreated. Health professionals should be prepared to ask appropriate questions when offering menopause counselling, and to ask them opportunistically, for example, when taking cervical smears, enabling women to feel able to discuss the problem openly.

References
1. Crandall C. Vaginal estrogen preparations: a review of safety and efficacy for vaginal atrophy. J Womens Health 2002;11(10):857–77.
2. Cumming GP, Currie HD, Moncur R, Lee AJ. Web-based survey on the effect of menopause on women's libido in a computer-literate population. Menopause Int 2009;15(1):8–12.

Resources
Menopause Matters
W: www.menopausematters.co.uk

British Menopause Society
W: www.thebms.org.uk