SEXUAL ACTIVITY DURING MENOPAUSAL YEARS

Many couples seem to have difficulty in sexual relations during and after menopause. This depend to some extent, as to how their relationship was in earlier years and what else is going on along with menopause, such as heavy and /or irregular bleeding problems. The other important thing is that two people are involved and it can be a problem with either of them. If a woman has had a hysterectomy this alone is often not a problem. However some gynaecologists think that removal of the cervix does interfere with the pleasure of sexual function, others think it does not matter. If one woman has had her ovaries removed it is a sudden withdrawal of ovarian hormones then they need help. If there are no contraindications for HRT, an ovarian implant is done at the same time. In early peri menopausal time women need to consider contraception, deal with hot flushes and a dry vagina. Their partner should understand and educate himself with these problems. If her desire to have sex is gone down perhaps more intimate time is required, gentle approach is necessary. If there is pain due to dry vagina there are many water soluble and silicone based moisturisers and lubricants available, which can make the sexual activity happy. Never give up, as sexual activity keeps the vagina healthy. It is said use it or lose it. Always pay attention to each other’s problems. You may consider MHT (HRT) if menopausal symptoms particularly hot flushes are making life difficult. When a woman starts having sex with a new partner always protect yourself from STD’s as your vagina is no longer protected and it may also be injured. The commonest infections are HIV, HERPES, and CLAMYDIA. There is a new SERM called Ospemifene is useful to protect from painful sex. Laser treatment is being tried but FDA has put up some warnings against it. Sexual activity in peri menopausal years requires personal, social, psychological and medical help.

PREMATURE OVARIAN INSUFFICIENCY (POI)

Premature ovarian insufficiency is defined when the ovaries fail to function before the age of 40.  This can happen very young, when a young girl fails to show the signs of puberty, or any time in her life before the age of 40. There are different names given to this problem, but the internationally accepted name is POI.  There is no ovulation and hormones, oestrogens, progesterone and testosterone are not produced. Besides reproduction these hormones are required for many functions in the human body, so the body suffers. I will explain this as we go along.

POI happens in 1% of women and 1 in 1000 women between the ages of 15 to 28. This is caused by chromosomal disorders, one of commonest being Turner’s syndrome. These women have only one X chromosome instead of two. These women have a fairly normal life when treated, except for fertility; the other chromosomal disorder is Fragile X mutation. The other causes are autoimmune diseases as in when the antibodies destroy the ovarian follicles, previous cancer treatments, metabolic disorders, toxins and viral infections. The special test required when these women or girls present to us are follicular hormone, oestrogens, chromosomes, genetic testing, thyroid function test, and antibodies. It is often very traumatic when women come to you hoping that they are pregnant and it is found that they have POI. In the management of young girls, once the diagnosis is established for sure; hormones are given in increasing doses to bring a period on and help with breast development. If they are really young growth hormones can be tried especially in girls with Turners Syndrome as they are short in height. This may help them to gain some height. Girls with Turners Syndrome need to be seen by a cardiologist who can look after any congenital heart lesion, as they often have them. Pregnancy can be tried with an Oocyte donation (a young egg from a donor) but this requires great care both during pregnancy and labour.  They are maintained on HRT at least until the age of menopause. These women with POI should be advised on general life style factors such as weight, cholesterol, smoking, as they have a higher risk of CVD due to lack of oestrogens. They can also try to get pregnant with an Oocyte donation. The age of the donor should be considered and screening should be carried out for any foetal abnormalities. If a woman is lucky to have a spontaneous pregnancy with POI, there are no special risks. Osteoporosis is another risk factor in women with POI; again due to lack of oestrogens, they should be having HRT, or a combined oral contraceptive pill, which will prevent any unexpected pregnancy if they do not want to be pregnant. If they have osteoporosis and require special treatment besides HRT, calcium, vitamin D and sunshine, it is best for them to be seen by an osteoporosis expert. HRT has not been shown to increase the risk of breast cancer under the age of 50. If any of these women are positive for BRCA12 (increased risk of breast cancer, and ovarian cancer) and there is no personal history of breast cancer they can have HRT but only after removal of both ovaries and tubes. Migraine headaches, fibroids, endometriosis, and blood pressure are not a contraindication of HRT in women with POI.  If obese it is better to use transdermal HRT. These women require a fair bit of psychosexual, psychological, cognitive, and life style intervention advice. Because of risks of CVS there life expectancy is shorter in women with POI. If they need help with genitourinary syndrome, they can be offered, local oestrogen creams, moistures and lubricants. They can read my previous posts on HRT and genitourinary syndrome. In short POI is perhaps a very premature menopause.

However it can be made very comfortable with all the modern treatments and in future we can achieve even more with regards to pregnancy.

CARDIO VASCULAR DISEASES IN PERIMENOPAUSAL AND POSTMENOPAUSAL YEARS AND ABOUT MHT(HRT)

We the clinicians as well as the women, all worry about hot flushes , night sweats , bladder problems, insomnia and mood swings, but do not think about heart problems in peri and post menopausal women .  However the fact remains that the highest cause of death in women after 50 is cerebrovascular disease (CVS) and stroke. These account for 75-76% deaths in western society as compared to deaths due to breast cancer which is 6-8%. Out of every 3 deaths in women 1, is due to CVS. We have to start paying attention to this and prevent them, from happening. There is a 10 years lag time when this happens in women as compared to men, unless women have a premature ovarian failure, premature menopause or early surgical menopause. Women lose oestrogen, this causes the blood vessels to become stiff, lose their elasticity, blood pressure increases and this increases the strain on the heart. The LDL (Low Density Lipoproteins) and Triglycerides (bad cholesterols) increase. HDL decreases (good cholesterol). Insulin resistance increases leading to, pre diabetes and diabetes as time goes on. Oestrogen also effects fat stores slows metabolism, this leads to weight gain and an increase in BMI and increase in abdominal girth. These are not ideal to prevent heart disease. The coagulation factors are altered, such as antithrombin3, factor 7c and plasma fibrinogen are all increased, leading to increased risk of thrombosis. So the risk of heart disease becomes multi factorial, there is increased blood pressure, strain on the heart, diabetes, obesity, changed cholesterol, increased thrombotic factors and increased sympathetic tone. All these lead to, metabolic syndrome and CVD. Some research has indicated that changes in cholesterol, apoproteins B, happen within the one year after the final menstrual period where as most other changes are related to chronological age.

What are the symptoms of CVS and heart disease? Heart Palpitations, Shortness of Breath, Light Headedness, Headaches, Diabetes, Swelling of the Feet, (change in the rhythm of the heart) Fibrillation, Pain in the Chest and Stomach. Women often do not have a chest pains when they have a heart attack. For neurological problems (Stroke); a women may not be able to smile put her tongue out and cannot lift her arms above her head (these are very simple test for the public to work out what is happening). Take them to a hospital immediately if this is happening. If stroke sufferers are treated within 4 hours they suffer very little residual damage. It has been shown that if treatment for prevention of long term CVS is started soon after menopause or within 10 years of menopause, these can be prevented.                        Most women need treating for hot flushes, night sweats, lack of sleep, mood swings, dry vagina and psychosexual problems, why not give them MHT (Menopausal Hormone Treatment) and not let them suffer and also prevent them from long term  effects of oestrogen deficiency such as increased risk of CVS and osteoporosis. This early period of menopause is called Xperiod of opportunity. Later on after many years of menopause, changes in women’s blood vessels have already occurred and oestrogen is not helpful. If a woman has a uterus and she needs oestrogen, she needs progesterone as well for uterine protection from cancer; a form of progesterone called micronized progesterone is recommended. This has fewer side effects and is better tolerated. For prevention of thromboembolic problems, dermal oestrogens are prescribed in the way of oestrogen patches and or jelly.  Women should watch their weight, abdominal girth, exercise, nutrition and quit bad habits such as smoking, excessive drinking of alcohol and soft drinks and being a couch potato.

It is very important to start MHT (HRT) during the WINDOW of OPPORTUNITY to prevent cardiovascular disease, which is the main cause of death in older postmenopausal women. The window of opportunity is considered to be within 10 years of menopause, or under the age 60.

There are many ways in which a woman can be relieved of her peri menopausal problems during the transitional phase or post menopausal phase. The most important thing is do not suffer in silence or follow the odd or non scientific, unauthorised, unproven solutions. MHT or HRT is probably the best solution for a long time or for the future prevention of complications and deaths from CVD or complications of Osteoporosis. Women who want to self manage their peri menopause can do this to some extent. They can watch their lifestyle factors, diet, exercise and yoga. Some selected antidepressants also help with hot flushes and sleep disturbances, these also can be tried. They need medical input if there periods are all over the place, too heavy and they are worried about contraception. When a medical care giver starts to look after peri and postmenopausal problems he/she takes a history in detail. This includes age, period history, your personal history of any medical disorders, DVT, CVS, liver and kidney disease, any operations, does she have a uterus or ovaries, does she need contraception, any family history of problems such as CVD, DVT or cancer. There will be a focus on women’s symptoms, irregular bleeding, anxiety, hot flushes, night sweats, sleeping problems, lack of interest in sex, dry and painful vagina, urinary problems such as urgency, incontinence and or repeated bladder infections. The clinician will do a detailed clinical assessment and look at a woman’s stature,   walking, vision and hearing. This can all be observed as she enters the clinic and says hello. He /she will take your weight, blood pressure or may be test your blood sugar. A breast examination is done, along with listening to the chest, abdominal examination and above all a vaginal / pelvic examination to find or exclude any local problem. Not many tests are required to make a diagnosis of menopause except in situations where there is a question of premature ovarian failure. It is not very rare if women came to you with a diagnosis of early pregnancy, (before the advent of such good pregnancy tests) ,the care giver finds, the woman in fact  is not pregnant and is suffering from premature ovarian insufficiency (PIF).  These situations are extremely distressing both for the care giver and the woman. Some of the tests that are ordered in peri and menopausal  are to assess ,her health such as FBE , ferritin (iron level in the blood), cholesterol ,thyroid function tests, liver and kidney function, mammogram, blood in stool, human  papilloma virus, now  instead of a smear test, pelvic ultrasound and any other tests if required in particular cases. With all this information the care giver is in a very good situation to discuss MHT with a woman depending on her wishes and symptoms. If you are under 60 or within ten years of menopause, this is what is called window of opportunity. It is the best time to start MHT if you so desire. It helps with your initial symptoms and prevents future problems such as CVD, osteoporosis and genitourinary syndrome of menopause. If a woman has had a hysterectomy the MHT (HRT) is easy to prescribe and take.  Normally women need two hormones, oestrogens for symptom relief and long term protection from CVD, osteoporosis and late onset genitourinary problems and progesterone is required for protection of the uterine lining the endometrium from cancer. Progesterone can be difficult to take for many women because of side effects, and it also increases the risk of breast cancer. When there is no uterus, progesterone is not required. It is easy to take oestrogen only. It can be used as oral, transdermal (on the skin) as a patch or jelly. It can also be used as an implant. Implants (deposited just under the skin for slow release) are used 6monthly or 12 monthly depending on the strength as to how long they will last).  Transdermal methods are very good if there is any history or risk factors for thromboembolic problems. In the early pre menopausal phase, if a woman needs MHT and her period is overdue always exclude pregnancy. One of the best MHT is combined oral contraceptive pill, especially if contraception is required and if there are no contraindications, for the pill such as high blood pressure, history of thromboembolic (DVT) problems or smoking. They come in different strengths depending on what is required to relieve a woman’s symptoms safely. For progesterone, what is currently used is called micronized progesterone. This progesterone is very safe and easy to tolerate. It decreases the risk of breast cancer. It can be used orally or vaginally, either continuous or 12 days in each cycle. However this regime is not a contraceptive and also does not help if a woman’s periods are heavy. For these situations an oral contraceptive pill which is good. If oral oestrogens are not suitable, transdermal oestrogens combined with a progesterone realsing intrauterine device is used, releasing a progesterone called levonorgestrel . This stops heavy periods or in fact periods all together and is a contraceptive as well. It is cost effective. This does not help with cyclical symptoms such as PMS, mastalgia, mood swings and fluid retention.

This works for nearly 5 years.  For more information on these you can refer to my previous post on bleeding problems, and contraception after 40. Women, who have early menopause, benefit from MHT. If they have an intact uterus, MHT with different types of Oestrogens and Progesterone is required, as already explained.

Combined oestrogen and progesterone patches are also available in varies forms.  They are useful if transdermal oestrogens are required. They can be cyclical or continuous.

Tibolone is another HRT often used for treatment in post menopausal women. It should not be used if a woman has not had a period for at least 1 year. It is a synthetic drug made from the Mexican yam. It can be used both in women with or without a uterus. It has oestrogenic actions on the brain relieving hot flushes, on the bone preventing bone loss and fractures and on the vagina improving vaginal dryness. It works like testosterone and improves sexual function and mood swings. There is some controversy about its risk on breast cancer. It is best to have regular breast examinations and mammograms. It has a slightly increased risk of stroke in women over 60. It is best not to use it in women who are over 60 or have risk factors for stroke eg: smoking, obesity, and high blood pressure.

IT should not be used, in women with a history of breast cancer or, for cardiovascular protection. Its data on LDL, HDL, and thrombosis risk are also inconclusive. Its side effects are headaches, nausea and swollen feet. Some women may have some bleeding in the initial 1-3 months, if it does not settle it should be investigated. The role of Tibolone on breast cancer is still under research.

One of the latest drugs approved by FDA for post menopausal women is a combination of combined   Estrogens and Bazedoxifene. Bazedoxifene, is a selective oestrogen modulator (SERM), this means that these oestrogens act differently in different organs. It is used for vasomotor symptoms and osteoporosis. This drug cannot be used if a woman has a heart disease, stroke, breast or uterine cancer, liver and kidney disease, dementia, blood clot, eye problems, migraine headaches, epilepsy, risk factors for coronary heart disease, thyroid function or high calcium levels in blood. Every woman should discuss with her care giver in detail that it’s safe for her to take this drug. Some side effects are diarrhoea, nausea, neck pain and upper abdominal pain. One of the serous side effects reported is sudden loss of vision. This is thought to be due to retinal vascular thrombosis.  Breast, ovarian and endometrial cancer may occur but this risk is unknown. Bioidentical hormones are promoted by many people instead of MRT. But these are not truly tested. This may be a euphemism for uncontrolled activity.

Non Hormonal Treatments of menopause

Some recent anti depressant called SSRIS (selective serotonin reuptake inhibitors, and selective norepinepinephrine reuptake inhibitors) and SNRIS are found very helpful for management of vasomotor symptoms of menopause, particularly in women who cannot take oestrogens. These drugs help to increase our levels of serotonin and noradrenalin in the brain; they are useful in transmitting messages from one cell to another. They are useful for vasomotor symptoms and mood swings. There are many such drugs. Your care giver will be able to give these to you. They are venloxifene, escitopram, praoxitin, prebgablin and many others. These normally are anti depressants, but when used for VMS of menopause they are used in a much smaller dosage. There is another drug called Gabapantin which is very helpful if there is pain as well with VMS. Normally it is used for chronic pain and epilepsy. Side effects can be dizziness, light headaches and drowsiness.  Clonidine is another useful drug, normally it is used for blood pressure or migraine headaches. All these drugs are particularly used for women who have suffered from breast cancer or any others cancers and these are non hormonal. They can use local moisturisers for the vagina, they last longer than lubricants. Silicone based lubricants are best.

There are many plant based remedies and food, however women who have had a history of cancer should stay away from them as they have not been evaluated. Other helpful counselling can be on sexual problems, bone health, life style changes, relaxation, no smoking and acupuncture is supposed to help some women. In very difficult cases Stellalate Ganglion Block is done, by injecting sympathetic nerves in the neck. A new class of drug is being studied in the Imperial College in London which may revolutionise the management of menopause. There are many new treatments for genitourinary syndrome of menopause, please refer to my previous post on this. Women who have had breast cancer cannot use Ospemifene, a drug mentioned there for dyspareunia. There are special situations when HRT should not be used. These are Oestrogen dependent cancers, high risk of DVT/VTE, personal wish not to use hormones, undiagnosed genital bleeding, severe liver disease, and untreated high blood pressure.  When any one uses a drug always read the information on side effects.

CONCLUSION:  This post discusses the prevention of CVD in older post menopausal women, which is the main cause of death in menopausal years. Various treatments of menopause are also mentioned. The most important thing is not to suffer in silence. There is a lot of help available in various forms and it is always discussed with every woman in detail. It is offered to women in total agreement with them. The most important scenario is to start it during the window of opportunity. Stay away from treatments which are not scientifically proven.