On the occasion of World Menopause Day 2021 (October 18), we turned to renowned expert Dr. Paula Briggs, who is a consultant in Sexual and Reproductive Health based at Liverpool Women’s NHS Foundation Trust. She is devoted to delivery of women’s health care, research and education. Her main interest is menopause management with a particular interest in urogenital atrophy. She has written various resources on this topic, including “Fast Facts for Patients: Menopause” and numerous articles for the website “Embarrassing Problems”.
Paula, first of all, when and why did you develop an interest in women’s health, especially in menopause and hormone replacement therapy (HRT)?
It wasn’t really a conscious decision. I originally worked as a general practitioner and I saw lots of female patients, I think because they naturally wanted to see a female general practitioner. Initially I provided mainly contraception, and it’s kind of logical to move into menopause management, as that is also clearly to do with hormones and with hormone deficiency. I’ve had an interesting career in menopause management. I’ve seen things go through peaks and troughs and I have never really seen that happen with any other specialty.
So, in 1993, we were giving most women HRT for a variety of reasons. And then of course in 2002 we had the Women’s Health Initiative published and that was very damaging. Women came off HRT, general practitioners stopped prescribing it, and it took a long time for things to recover. And then in 2015 we had the publication of the National Institute for Health and Care Excellence (NICE) guideline that was very clear and very positive. At that point we started to provide individualized care, ensuring that women were listened to, which hadn’t happened for a long time, and they were prescribed HRT if that was the right thing for them.
“In a way it is great that there has been a lot of publicity about menopause.”
In a way it is great that there has been a lot of publicity about menopause. But HRT is not a cure all, and I think those consultations with menopausal women are an opportunity for them to take stock, to look at how they are managing their life in general, what they are eating and what they are doing. It is often a time when women’s children have left home and they might be left together with their husband, which hasn’t happened for a long time. So, it’s a time for them to focus on their own relationships.
There is no reason why older women shouldn’t have sex and that’s partly why I developed an interest in urogenital atrophy because if you ask women about symptoms such as vaginal dryness, itching or burning pain during sex, many of them will actually say “Yes, that is a problem”. However, without the support and being asked, they are very reluctant to ask for help and they assume that that’s a natural part of aging, which it doesn’t have to be.
Until quite recently, menopause and HRT were the “Dark Lord” of women’s health, or the “You Know Who” topic not openly discussed. So, how did this change?
I think, certainly in the UK, there has been a lot of celebrity interest, media interest, social media interest and a lot of traffic, which has pros and cons. I deal with many women who have experienced hormonally dependent cancers, and these are relatively young woman who are not always excluded from HRT, but in many cases are either unable to take HRT or reluctant to do so for obvious reasons.
So I kind of feel that it is better really to perhaps take a little bit of a step back at this point to ensure that women are not using excessive amounts of hormones to fix everything that might be wrong because that’s never going to work. Moreover, we should also focus on women who can’t have HRT and think about alternative methods of managing menopause. There are many new things coming to market; new non-hormonal drugs to manage hot flushes, night sweats, and difficulty sleeping, and also non-hormonal treatments for urogenital atrophy, such as laser therapy.
“There are many new things coming to market.”
Irregular periods, hot flushes, sleeping disorders – these are the symptoms most commonly associated with menopause. What other, lesser-known symptoms should be considered by women and their doctors?
I think that mood disturbances are less well-recognized. Anxiety, loss of confidence, brain fog, loss of libido, generalized aching, just feeling “old” are symptoms often experienced by women. Now, there will be an element of symptoms such as these as women age and their body is deteriorating a little bit. However, I think that hormones do play an important part in muscle mass and in tissue quality. I genuinely believe that patients will associate hot flushes, night sweats, menstrual disturbances, and difficulty sleeping with menopause. But if they suddenly become extremely anxious, unable to cope, and unable to function in the workplace, then they are less likely to associate that with menopause. What I have just described really are short-term symptoms, although they can last many years.
Intermediate consequences of hormone deficiency include urogenital atrophy, which doesn’t just affect the vagina; it affects the bladder and it can lead to recurrent urinary tract infections. And then we have the longer-term consequences associated with hormone deficiency: a reduction in bone mass – women will lose approximately 1% of their bone mass per year when they are estrogen deficient as a result of the menopause, and they will also have an increase in cardiovascular risk.
“I think that hormones do play an important part in muscle mass and in tissue quality.”
But it’s not just about focusing on hormones. I think that a menopause consultation is an opportunity to check blood pressure. We know that 50% of women roughly have high blood pressure by the age of 50. And if we treat that then we reduce their overall cardiovascular risk. And if we talk about general risk reduction, for example if the patient is overweight, to support her to lose weight will reduce her risk of becoming a type 2 diabetic with all the consequences that come with that. So I really do think this is a time in a woman’s life when we can make a huge difference with the right information delivered to the patient.
Thus, the correct information is crucial and I think the social media input is helpful in a way because it raises the profile of menopause, but it is very difficult to know what information women are accessing. Therefore, I think that the Fast Facts booklet for women is an extremely valuable resource because it is evidence-based. We just updated it and, from my point of view, I know that when I provide my patients with that resource that they are then provided with the right information.
So, you mentioned quite a bunch of symptoms. Can you tell us a bit more about urogenital atrophy?
Yes, so about 80% of women, roughly, will suffer the consequences of a lack of estrogen on tissue quality in the vagina, but also the vulva, which is the outside, the bladder, and also the urethra. In a healthy vagina, which has adequate estrogenization of the tissue, the superficial layer of cells is thick. It sheds roughly every four hours, and those cells are full of glycogen, which supports lactobacilli, the healthy vaginal bacteria.
“About 80% of women, roughly, will suffer the consequences of a lack of estrogen on tissue quality in the vagina, the vulva, the bladder, and the urethra.”
So we all have lots of different organisms in our vaginas, but if the patient has a lack of estrogen, and that means that the superficial cells are reduced and there is less glycogen, then there are less healthy bacteria and the other bacteria start to overgrow, such as Escherichia coli. In this condition the urethra becomes much more prominent. It is short in women anyway, and the natural course for these non-healthy bacteria is to ascend the urethra into the bladder and cause recurrent urinary tract infections which can be very debilitating and can lead to treatment with long-term antibiotics and difficulty functioning in the workplace. I think, though, that we have a workforce that is made up of a huge number of women who may be affected by lack of estrogen.
In addition, we see women experiencing vaginal dryness, itching, burning, and with the folds in the vagina lost, the capacity to stretch is reduced. It becomes shorter, you can get loss of the small lips, fusion of the lips over the clitoris so sex becomes less pleasurable and ultimately, for some women, completely impossible. Providing women with the information at the outset enables them to have treatment earlier on, and that reduces the risk of these potentially irreversible changes in tissue quality.
What are the current developments regarding information, treatment and support for menopausal women?
I think there are lots of resources available for women. I think it’s important that women access the right resource to inform them about the best way of managing their menopause, and I think that that’s much better provided early on. This is a journey women are going to spend approximately a third of their lives post-menopause. So we have reproductive life, and we have the menopause transition when their hormones are all over the place, relatively speaking. And then post-menopause when hormone levels are low.
I am chairman elect for the British Menopause Society. We have a patient-facing arm, Women’s Health Concern, and we have lots of valuable resources for patients there. I worked with Karger on Fast Facts, and that resource was recently updated which I think is important, and the feedback from patients has been very positive. So this is education for patients and education for providers of menopause care, which will largely be general practitioners. And I feel that women are entitled to good quality menopause care as part of the National Health Service (NHS).
“Women are going to spend approximately a third of their lives post-menopause.”
Ideally, this would be provided by general practitioners. Only those more “complicated” women that I touched on before, the women who have had cancer or also women who have premature ovarian insufficiency previously known as premature menopause – I think those particular patients are best managed as part of a multidisciplinary team. In my opinion, one of the most important aspects of menopause care is collaboration. So we collaborate with hematologists in regard to venous thromboembolism, blood clots in the leg and the lung, and I work very closely with the gynecologists and with the breast cancer teams. I think that is important so that every decision that is made about care is informed and is not taken without a discussion and considerable thought.
Very good, so there is a lot going on for women in menopause. There are so many important topics we would love to talk about with you, but for now we just thank you for answering all the questions on menopause. Thank you very much, Paula.