During Women’s Health Month, Miss Rhiannon Bray Consultant Gynaecologist and Urogynaecology specialist at New Victoria Hospital, talks about common urogynaecological problems during menopause and gives advice on treatment options.

Menopause and women’s health

The average age of menopause in the UK is 51, many women around 45 will be entering the perimenopause phase and their oestrogen levels will be starting to drop. These declining levels of oestrogencan play havoc with the body, affecting our thought processes and emotions, cause sleep problems and lowered libido as well as a variety of other symptoms,  so it’s important that women understand what to look out for, what may be considered normal and what’s not.

Pelvic floor health

Where the pelvic floor is concerned, the main impact of ageing on the vagina and the hormonal changes associated with menopause is the increased risk of prolapse and atrophy of the vaginal tissues. Oestrogen is one of the main female hormones responsible for keeping the skin of the vagina healthy, strong and lubricated, it also encourages the growth of healthy bacteria within the vagina which can prevent recurrent urinary tract infections. 

Prolapse

Vaginal prolapse occurs when the front or back walls of the vagina come down. Uterine prolapse occurs when the muscles and tissue in your pelvis weaken allowing your uterus to drop down into your vagina. These types of prolapse will often co-exist. Common symptoms include leakage of urine, fullness in the pelvis, bulging in the vagina, lower-back pain, and constipation. Women may also feel a lump or a bulge in the vagina or a sensation of something coming down. This often presents after menopause begins, as lowered oestrogen levels can contribute to weakening of the pelvic floor. 

Prolapse can also cause difficulties with passing urine or opening the bowels and this may require treatment.  Due to the lack of oestrogen in the tissues of the vagina women may be more vulnerable to urinary tract infections or a dry and uncomfortable feeling within the vagina, this is called genitourinary syndrome of menopause. If prolapse symptoms are affecting quality of life then women should consult the GP or a specialist with expertise in this field such as a urogynecologist.

The first line treatment for prolapse can often be pelvic floor exercises which can be very effective.  If these are unsuccessful then there are options of surgery or devices called pessaries which sit inside the vagina (can’t be felt) and support the prolapse.  As with anything, prevention is better than cure and we recommend a life-long commitment to pelvic floor exercises.

Surgery

Where pelvic floor exercises have not been successful in relieving the symptoms of prolapse a woman may wish to consider surgery. Surgery for vaginal prolapse is termed a ‘pelvic floor repair’, and involves stitches to support the front and back walls of the vagina.  When the uterus is coming down there are a variety of options, including a hysterectomy performed through the vagina or operations to lift the uterus which can be done through the vagina or the abdomen.

Urinary Tract Infections

Lower levels of oestrogen can make women more prone to urinary tract infections (UTIs).  When the vaginal tissues are thinner infection can more easily ascend into the bladder and cause a UTI.  Topical oestrogen can strengthen these tissues and prevent infection.    Oestrogen supplementation can also encourage the presence of healthy bacteria within the bladder which can further prevent UTIs.

Women are also more likely to experience perimenopausal bleeding problems, such as heavy or irregular periods or bleeding between periods. Some degree of heavier periods can be common but persistent bleeding between periods, pain or pressure symptoms or any bleeding after the menopause (1 year without periods) should prompt women to see their GP for investigation.

HRT and other treatment options

Perimenopause can also present with a long list of more generalised symptoms such as brain fog, mood changes, anxiety, tiredness and cognitive impairment, which can all be treated with HRT.

Thanks to a growing menopause awareness movement vaginal oestrogen supplements have been reclassified so that they can be purchased over the counter. This move has increase accessibility to HRT. 

From the 1st of April 2023, a Prescription Prepayment Certificate will be introduced to support women with menopause get easier access to HRT products.

Many women feel reluctant to start any form of HRT as they are concerned regarding side effects, however when used in the vagina negligible amounts are absorbed into the blood stream and side effects are not a concern.  This reclassification may go some way in alleviating some of these fears and help many women. 

There are also a number of devices aimed at helping women to perform pelvic floor exercises, such as vaginal weights or devices worn inside or outside of the vagina called ‘pelvic floor trainers’. These can be great if they encourage women to stick to a programme of pelvic floor exercise, but there is no evidence to say they are any more effective than pelvic floor exercises without a trainer. However, for those women who are unable to effectively contract their pelvic floor the recently published guideline from NICE (National institute of clinical effectiveness) suggests their use may be helpful.

For the reasons previously described urinary tract infections can be a big issue for women in the menopause. It has long been believed that urine was sterile. However, we are in an exciting time when it comes to bladder health.   New techniques of urine culture and DNA sequencing have revealed a thriving community of bacteria and probable viruses, fungi and yeasts in the human bladder, known as the urobiome.  Cutting-edge research is endeavouring to elucidate the role of these communities within the bladder and how they are responsible for your bladder’s health. The optimal characteristics of the urobiome are not yet known, but we believe some bacteria may play a protective role in the bladder as they do in other biological areas. Interestingly in postmenopausal women with bladder symptoms, replacing vaginal oestrogen, which is lacking after menopause, has been linked to an increase in Lactobacillus in the urine of these women, which is thought to be a protective bacteria. With this new information will come the opportunity to revolutionise future treatments and bladder health for women. 

If you are concerned with menopause symptoms and other urogynaecology ailments, you can contact New Victoria Hospital’s specialist by calling us on 020 8949 9020 or filling in our online form.