The Dr Louise Newson Podcast - 067 - Genitourinary Syndrome of the Menopause - Professor James Simon & Dr Louise Newson

Episode Date: September 29, 2020

In this podcast, Dr Louise Newson is talking with Professor James Simon about Genitourinary Syndrome of the Menopause which affects the majority of women after the menopause and can include symptoms such as vaginal discomfort, irritation, dryness and pain during sexual intercourse. However, only the minority of women currently receive treatment and this needs to change. Treatment with localised oestrogen can be very effective for the majority of women and is very low risk. Other symptoms related to this condition include urinary symptoms and Prof Simon talks with Dr Newson about how common urinary infections and consequent sepsis can be and how this can be avoided by using vaginal oestrogen.  Professor James Simon's Three Take Home Tips: Bring it up with your health professional and be direct. Speak to them about about when you are experiencing pain. If one treatment doesn't work for you - make sure you don't give up. Speak to your doctor about an alternative and remember that women often need more than the standard dose. Remember that urinary tract infections and urinary symptoms are part of the whole syndrome. You can treat those symptoms and infections by taking care of the vagina and vulva as a whole. Find out more about Professor Simon by visiting his website here. Find Professor Simon on Facebook: @IntimMedicine Twitter: @IntimMedicine Instagram: @menopause.whisperer

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newston Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today on popular demand, I have managed to entice Professor James Simon back to the studio, who some of you, I'm sure a lot of you, have already heard his podcast that we did before. So today we're going to talk again about the menopause, but we're going to talk about something called GSM, which is genitue-Ewine-syndrome of the menopause, which is a bit of a mouthful, but I will let Professor Simon explain more.

So welcome today. Thanks for joining me. Thank you. Thank you very much for having me. We talk quite a lot about menopause, HART last time, different types of HART, how safe it is, how effective it is for a lot of women. And we talked about symptoms. But by far the commonest symptom is the one that's probably least spoken about, or group of symptoms, should I say.

So could you just talk about GSM, what it is and what it means and why women experience it? Certainly. This is actually a very important subject, both from the public health, but also from the standpoint of maintaining healthy relationships. and those go beyond just intimate relationships as women age. So genitone urinary syndrome of menopause is a relatively new term. It was coined by a worldwide group of experts in response to the following problem. The symptoms are universal. The cause is well understood.

But most women attributed the symptoms to just growing older, rather than attributing them to hormonal changes during menopause. And so what used to be called vulvar and vaginal atrophy, which is a horrible-sounding syndrome, vulvar and vaginal atrophy, oh my goodness, was renamed GSM because we wanted to tie the symptoms to the menopause. And the basic issue here is that unlike hot flashes or flushes and night sweats, disturbed sleep and mood changes, which occur quite early in the menopause transition

or after the last menstrual period, GSM or vulvovaginal atrophy symptoms occur five to 10 years after the last menstrual period by and large. And so women never really equated them with a menopause or a hormonal event. And so we renamed it in hopes of doing two things, tying it to the menopause and also emphasizing the urinary tract as part of the syndrome. So genitone urinary syndrome of menopause. And women also don't realize that the changes that occur at menopause put them at higher risk

for urinary tract infections, which can be quite severe and have a big public health toll, as well as those symptoms of vulvar and vaginal atrophy, pain with sex, dryness, both with sexual activity and any kind of contact, or what I like to call walking around dryness, the sensation of just being dry down there. And it's a huge problem. I mean, it varies, doesn't it? depending what you read. I've read some studies say 40, 50% of women, but actually other studies say 70, 80% of women. And these are women postmenopausal or menopausal, but who aren't receiving hormones.

So it's the majority of women, isn't it, have some symptoms. So it really depends what we're talking about. And this is the way I would explain it. 100% of menopausal women will develop the visual signs of genitoneary syndrome of menopause. The tissue changes. They are inevitable and universal. But depending upon a particular patient's sensibilities, whether they're having sex of any kind, etc., they may have symptoms of that genital change. So let's just broad figures. If 100% of women develop this by age 60, obviously less than 100% of 60-year-old women will be having sex. So pain with sex might not accrue to them. And therefore, when we read, as many studies have shown, that 50% of women with GSM have painful sex,

it explains why it's only 50% because fewer of them are having sex than 100%. And many of them may not have pain with sex because they have enough moisture of their own. They have a vulva and vagina that's not very problematic for them in terms of their current partner. Maybe they don't have penetrative sex, but they have all kinds of other kinds of sex. I'll tell you a little funny story. This is me speaking to you as a much younger gynecologist where my naivete made me think that all couples had, all heterosexual couples, had penis and vagina penetrative sex as their sex. And I had a patient, and I asked all of my patients about sex in one way or another. I had a much older woman.

married. If I remember correctly, she was in her mid to late 70s, and her vagina was nearly completely closed. And I asked her whether she was having sex, and did she have any problems with sex? And she said, no, everything's fine. My husband and I have a great sex life. And I'm thinking, oh my goodness, how could this woman possibly have sex? And she said, well, we just don't have penetrative sex, Dr. Simon. We have other things and everything works just great. So we should avoid assumptions about people's sex lives and what they do or they don't do in our discussions of sex.

And it's very important, isn't it? We have a questionnaire. We do a menopause symptom questionnaire in our clinic for all our patients and it does ask about libido on it. And actually, when I talk about sex and like you, I do ask as many patients. appropriate about sex. And for a lot of them, they're really relieved to talk about it. They've never spoken about sex to any other physician. And for a lot of women, they say, well, I haven't

actually had sex for three years, for five years, for sometimes 15 years. They adore their partners, but it's so painful. The lady recently told me it was like having a red hot poker shoved inside her. And I said to her afterwards, didn't you talk to your partner? Didn't you tell him how uncomfortable it was. And she said, no, we hadn't had sex for such a long time. He was so desperate. I just knew it would be over soon. And I thought, God, how sad that not only she'd not talk to a partner, but she couldn't get help. She didn't know how to. And she thought it was just part of getting older. She would have to put up with having such uncomfortable penitative sex. And, you know, that's sad, isn't it? Really sad. Very sad. But your experience and hers have been

documented to be the norm, not the exception. And it brings up a couple of very important points for your audience. First is that if they don't bring it up, if the patient herself doesn't bring it up, the practitioners are unlikely to bring it up. And this is not about a particular individual. It's about anything that is vaguely related to sex of any sort. So if a woman, is having a problem, she needs to bring it up. Hopefully she'll have someone like you who is bringing it up for them and opening the door to their commentary. But the best thing to get this problem addressed is to bring it up as an issue. That's number one. Number two, most practitioners underestimate the pain, the degree of pain involved. Now, what I would say,

say is that maybe older menopausal female practitioners who have experienced it themselves may estimate the pain properly. But even under those circumstances, everyone's experience of pain is different. And for many, many women in this setting, they have terrible pain, actually horrible pain, like your patient said, like a hot poker was put up inside. And this has been described multiple times and is in the literature. Even when it comes to dryness, descriptions like having sandpaper rubbing against my underwear constantly or shards of glass in my underwear, these can be rather disturbing if they're brought up, and most importantly, both in the UK and across the pond here in the US, we have innumerable treatments for these problems, and they work

incredibly well if they're used and used properly. Absolutely. And I was lecturing some doctors a couple of years ago, specifically about vaginal dryness with GSM. And one doctor afterwards said, well I'll only ever talk about it or bring it up or ask a lady if she is having sex. If she's not sex, she's not sex, then it doesn't matter, does it? And I said, well, of course it does. These women still sit down. They still walk. They still exercise.

And so many women I talk to find they have to look at the type of chair before they sit down because otherwise it's so uncomfortable. A lot of them don't wear underclothes because the friction is hard. And the number of women who've told me they've stopped cycling. They've stopped exercising because, as you know, the vagina is. supposed to be very elastic and that elasticity goes and it can be incredibly uncomfortable and some people find the pain comes on very gradually and other people it's literally overnight. I'm sure it's from your experience as well that some people just say they're absolutely fine

and suddenly they get this searing pain and it will not go and it torments them and it seems to be worse at night as well. Everything's always worse at night, isn't it? But, you know, if you're not sleeping well because you're menopausal and then you're getting this pain, It's just awful. Well, think about it this way. Most of our body parts that are meant to be open and exposed to the environment, that aren't skin covered, are meant to be moist and slippery. Your eyes tear, your nose runs, your mouth drools,

and a woman's vagina is supposed to be moist. many women in the age group were discussing don't remember that they used to have natural moisture down there and that that moisture kept everything slippery even when they weren't sexually aroused. And then when they were sexually aroused, they had lots of their own lubrication in addition to that. So we need to keep this in perspective. If your eyes were very, very dry and every single, speck of sand, dust, or whatever, got in your eyes and stuck there, believe me, you would seek attention for that. And it's very important to remember these just normal bodily functions,

because this one, that is to say, normal vaginal moisture and vaginal elasticity acceptable for sex, these are things that are very easily forgotten and can get in the way of couples' intimacy, and their long-term relationship. And I'll just bring up again, urinary tract infection. For an older woman who may not have a partner, may not be having sex, may not be having any form of penetration whatsoever, it's still important for her to keep the vagina healthy to reduce her risk of a urinary tract infection. And urinary tract infections are increasingly prevalent in women as they age and are really important problem in assisted living and nursing facilities where they're treated over and over and over again with antibiotics rather than seeking some form of preventive therapy.

And it's so important because there are estrogen receptors, aren't there, on the cells in the bladder, in the urethra, the tube that we urinate out of, also in our pelvic floor as well. but Euro-sepsis or sepsis due to urinary infection is very common and elderly women, far more common than men. And we've just done a survey actually with UK Sepsis Trust looking at this very subject and looking at women who have recurrent urinary tract infections and asking, did anyone talk about vaginal estrogen with them? And you can imagine what the results are like and they're very disappointing. But because people don't think about it and certainly 10, 20 years ago,

I never thought about it because no one had taught me there was a link and that we should be giving vagina and estrogen to women with recurrent urinary tract infections. It's all about antibiotics and how wrong is that because we know we shouldn't be over-prescribing antibiotics. And a lot of these women don't have proven urinary tract infections. They have urinary symptoms, don't they? And so if any of you are listening are having symptoms that you think might be due to a urinary tract infection, but your doctor says you don't have an infection, you need to be thinking about your vagina and having treatment. And just explain then. So vaginal estrogen is not the same as HRT because it's not systemic, is it? It just works locally but can help the urinary system as well. So how does it work? What is it?

So let me tell you a relatively long story because I think it's incredibly important and it will answer your question, I promise. So remember I said that each of our mucus membranes, body orifices, et cetera, that are exposed to the environment, have their own mechanisms for staying clean and moist and safe. Well, the vagina is open. It's open. It's actually an incredibly risky pathway from the outside environment, up the vagina, potentially through the cervix, uterus tubes.

and into the peritoneal cavity. So it is, on some level, a mistake of Mother Nature putting human females at risks of peritonitis, and that was all done to have sexual reproduction, recognizing that in many lower animals, there's reproduction without any sex. So how did Mother Nature protect women from this type of crazy ascending infection

and at the same time protect the urinary tract from infection as well. Well, this was evolved in a very simple, straightforward way. Mother Nature made the vagina the second most acid place on the human female's body after the stomach. and the stomach has acid for all kinds of different reasons, but the vagina, normal pre-menopausal woman's vagina, is very acidic, acidic enough

so that under normal circumstances, the acid in the vagina kills bacteria, fungus, and viruses. Those are great things, but Mother Nature made a little teeny mistake, because under those same circumstances, the acid in the vagina also, kills the sperm and would make it impossible for reproduction to occur. So there's a safeguard. Mother Nature thinks of everything. And the mucus in the cervix during ovulation, the only time that reproduction would occur anyway, is of a pH that's perfect for human sperm, protects the sperm from the

otherwise acidic vagina for 24, 48 hours when that human female is fertile, reproduction happens, and babies get born. But at the same time, the vagina maintains its acidic environment and can prevent infections in both the bladder and urinary tract. So this system, unfortunately, kind of goes to hell in a handbasket when the the normal hormonal milieu of menopause kicks in. So with reduced estrogen made after menopause, there's less acid made in the vagina

and therefore less protection of that woman's vagina, urethra, and bladder. And this is why estrogen in the vagina, even if it's local, or medications, and you have some in the UK that aren't actual estrogens, but behave like them in the vagina, can prevent ascending infections in the vagina and in the lower urinary trend.

Which is so important because they work in so many different ways, like you say, they can change the pH, the acidity, but also they can thicken the wall of the vagina, make it more elastic, help with secretion, but also it can help with the lining of the urethra as well. So a lot of women find they have infections after intercourse, for example, and there's more friction, isn't there?

And you can imagine if the cells are thinner, then more likely to have irritation, more likely to have bugs that ascend and cause urinary tract infections. So the local estrogen is very safe to use. It can be used as a pezzary, a vaginal tablet, a cream. There's a ring as well that we often use, especially I've used a lot in elderly people who are less manually dexterous because it can last for three months. So it can be very useful for some women. But any woman can use that,

can't they? Even women who've had breast cancer, there's no risk because it's very low dose and it just works locally. Yes, I would completely agree with you. But many women who have a breast cancer fear even these very small local doses. And obviously they need to have a heart, talk with their practitioner to determine where the benefit and risk balance is for them. I'll also point out that the youngest women with breast cancer often have a form of breast cancer that's not hormone dependent and are the ones who are most likely to be having sex as well or more frequent sex, and they can use vaginal estrogen with impunity because there's no way that that vaginal estrogen either escapes the vagina or can adversely affect their breast

cancer. And this is often a subtlety that's lost on many of their practitioners. There's one other thing that I want to bring up, and that is that some women who have gone a long time without sex or who have very severe symptoms or severe degrees of GSM or vulva vaginal atrophy may actually require physical therapy or physical self-dilation before they can resume any sexual activity. but there are very, very few women who, with that kind of dilation and physical therapy and the benefits of estrogen or medications that act like estrogen in the vagina, there are very, very few that can't resume a healthy sex life with their partners. And that's so important.

I remember seeing someone in my clinic a while ago who hadn't had sex for about eight years with her partner, and she had quite severe symptoms. And with time, with treatment, she's resumed a sexual relationship with her husband, but it took about 18 months, long time. And it's very important that people go at the right pace, that they know that there's different treatments. And sometimes, for example,

we use internal vaginal estrogen, such as the pezzary, like I mentioned, and then there's estrogen creams that can be used externally as well. And some doctors don't always prescribe both because they think it's going to be too much. But it's very safe, isn't it, to use internal and external estrogen because each of these products, the dose is very small indeed. And some women actually find that they need to use slightly more than the licensed dose to have an effect. The other thing is, is that these treatments need to be used forever, don't they? They're not just short-term treatments.

Yeah, this is actually a very interesting phenomenon, at least in the U.S., and there's abundant supporting data for this in the U.S. I don't know about in the U.K. But women tend to use these treatments until their symptoms get better, and then they stop using them until their symptoms get worse, and then they start using them again and the symptoms get better, and they end up on this roller coaster rather than just using them for. for very good health maintenance. The way they do lots of other things, they get on the treadmill on a regular basis

so that they don't gain weight. They don't get off when they've lost down to their normal weight because they know if they stop exercising, they're going to just gain it back. So these are lifelong treatments. They can be relatively inexpensive. They can be relatively expensive. unobtrusive and none of them that I'm aware of can hurt their partners, which is another

concern. The elderly woman who's on local vaginal estrogen now has a new love in her life and her otherwise uninitiated new boyfriend wants to know if he's going to grow breasts by having sex with her because she's using estrogen in her vagina. And that's a common misconception. Yes. No, and that's very, very important point. And in fact, I recently authors just an article for a website to help GPs in the UK. I'm not going to say which one it was, but I wrote this article for them. And then someone alerted me a couple of weeks ago because there was an error in it. And I went back to it. And I'd seen that the original author had changed my words. And instead of saying, review ladies every year, he said,

review ladies every year and stop their local estrogen to see whether it's still having an effect. And it's just so wrong because as soon as the localised estrogen is stopped, symptoms will return. And if the symptoms don't return immediately, they will return eventually. And it makes the lining of the vagina thin again, more prone to urinary tract infections. So it really is important that women have these prescriptions on a repeat prescription and they are encouraged to take them forever because once women are menopausal, their hormones are going to be low. But actually, even if women take HRT,

they still can develop these symptoms of GSM, can't they? There are, I think, about a fifth of women who are on HRT who still need to use localized estrogen. And that's very important, isn't it, to know? Yeah, that's also a problem for many practitioners. they think that if a woman is on systemic hormone therapy, that it's literally impossible for them to develop local symptoms. And I think you're spot on that about a fifth of women, maybe even as many as a quarter of women, would benefit from having some local estrogen or estrogen-like therapy,

even if they're on systemic treatment. And one other thing, those women may be very well. well estrogenized in the vulvan vagina and still may benefit from adding a lubricant during sexual activity or adding a moisturizer to their vagina in addition to whatever vaginal hormone treatment or systemic hormone treatment thereon. So it's a little bit different for everyone, but there are ways to optimize the health and well-being of a woman's post-menopausal sex life, and not everyone is the same. And that's so true, and not everyone's the same, and things change with time as well. And certainly, whenever I review a lady, I would always ask whether she's developed any symptoms related to GSM, because they might not think about it's being

associated with their hormones. And it's so rewarding as a physician. to treat and manage and help these women. And although at the beginning you said, usually it's symptoms that come on, sort of classically five, ten years after the menopause, there are some women who experience it as their first symptom and their perimenopausal. You know, you can't predict, can you?

Who's going to get it and how quickly it's going to come on and when it's going to come on? But the important thing is to get help, isn't it, as soon as symptoms does? Absolutely. And there's one more thing that I'd like to mention, and that is that as women age, so typically do their partners. And while men have had multiple treatments for erectile dysfunction for decades now,

we see commonly that as men age, they may need a different amount of treatment for their partners in order that the two of them have satisfying sexual activity together. And so while the entree to our talk today was specifically about Volvo vaginal atrophy or genital urinary syndrome of menopause, we need to educate the male partners, and we need to make sure that if symptoms occur abruptly, that it's not just because he now has violations, Diagrilavitra Cialis or whatever, but that they are both being taken care of in this setting. And I think you as a general practitioner are much more likely to hear about the male partners,

etc. But the gynecologists may take a very focused view on her without looking at her partner or her multiple partners. And I think that's so true, isn't it? My husband's actually a urologist and he does a lot of genital reconstructive work. And because all I do is talk about the menopause, he's really changed his practice over the last 10 years or so. And when he treats men successfully, he will automatically ask about their partners. If he says to them, do they have any dryness? They'll say no.

But then if they say, does it feel different? Are you needing to use some lubrication? And then they'll often say, well, actually we do, but it's fine. and then, well, have you thought about her having some vaginal estrogen? Oh, what's that? And he's often prescribing it for the women in the clinic. And they come back and say, wow, that's made the most amazing difference. Not just to their sex life, but just the way that they feel.

And as so many women just say, going to the toilet, it's very uncomfortable just wiping themselves. You know, but they just think it's part of getting older. And it's so important. And I'm sure, you know, the majority of women listening, if they're not having symptoms and they've still got mothers, their mothers definitely will be having symptoms because there's this lost generation of women who aren't taking HRT for various reasons

that we've already discussed on podcasts. And these women really should be considering to have vaginal estrogen because it's never too late, is it, to start using it? Yeah, I like to say that the vagina has a very good, nearly perfect memory. And if it has all the right hormones, attributes, etc.

Stimulation included, then it will remember how it's supposed to behave and feel and that's to everybody's benefit. Really important. So what a great way to end. So just before we end, I'd just like you to give three take-home tips

in my usual style. So three tips, maybe for women who are listening and thinking, actually, that might be me. But how do I talk to my doctor about it? So what would you recommend? How could people bring it up in a conversation and actually get the right treatment as well? So whether or not your practitioner brings it up, you, the patient, have to bring it up.

And you can bring it up in a variety of ways. But I think the best way is to just let it out there, say it like it is. I have pain with sex. I have dryness with sex. I have pain or dryness just walking around or wiping or when I urinate, it really burns on the outside before I have a chance to get the urine off. These are all things that should alert your practitioner to something, to at least looking. Many times they don't even look. You can make a presumptive diagnosis over the internet, but you can't really get a definitive diagnosis.

without actually examining the patient. So number one recommendation, look it up. Number two, if one treatment doesn't work for you, make sure you don't give up. Make sure you circle back and talk to your practitioner about an alternative. Sometimes, as was mentioned, women need more than the standard dose, or they need, in addition, some physical therapy or self-dilation or some other treatment along with what is ever the standard treatment. And then last but not least, remember that urinary tract symptoms, whether they're actually urinary tract infections or just symptoms that are urine-related or urination-related

are part of the whole syndrome. And you can treat. those urinary tract symptoms, including recurrent urinary tract infections, by treating the vagina and the vulva. And so it's all one package, and it should be taken care of the way anyone would take care of the rest of their bodies. Really important, really, really clear advice. And thank you so much for your time today. It's been really informative, and I know it will help so many women and men as well. So thanks ever so much, Prof Simon, for joining me today. It's really been my pleasure, and I'll send you over some PowerPoint slides that emphasize the points we've discussed today and hopefully drive them home for your patients and their practitioners.

Thank you so much. Thank you. For more information about the menopause, please visit our website www. www.menopause.com.com. Thank you.