Friday, 18 November 2016

What do you know about prolapse?

Let's talk about prolapse...

What’s the best way to talk about prolapse?

It seems to me that women are better now at talking about bladder leakage – either to their friends or their GP – using phrases such as ‘don’t make me laugh’ or ‘I couldn’t go on a trampoline’. A ‘legs crossed and oops’ moment with a sneeze is easily understood and ‘wearing a pad just in case’ doesn’t need to be said in hushed tones.

The products for incontinence are much more available and taking up more and more space on the shelves – for men and women. We can also talk about the effects of ageing on the body: ‘everything heading south’, ‘not as young as I once was’, ‘laughter lines’ not age creases. I have been a specialist women’s and pelvic floor physiotherapist for over 20 years but don’t yet have the answer to “What is the right language to talk about prolapse?”

What actually is a prolapse?

Prolapse is a very common problem for women who have had children, and the risk of prolapse increases with each decade of life. Estimates are that up to 50% of all women will have a prolapse at some point in their life. Prolapse or pelvic organ prolapse is where the walls of the vagina or the uterus (womb) move downwards creating a feeling of something coming down, vaginal heaviness or bulge.

It does not always have to involve the uterus, and although some people talk of their ‘bladder falling down’, it is the wall supporting the bladder rather than the actual bladder itself. The same goes for the back wall of the vagina, which is the one that supports the bowel or back passage. You can still have a prolapse even if you have had your womb removed (hysterectomy), in which case the ‘roof’ or top of the vagina can slip downwards.

The heavy feeling associated with a prolapse may not be the most bothersome problem. Prolapse may also cause difficulties with your bladder or bowel either with leakage or problems emptying your bladder or bowel completely. This can cause a sensation of never feeling properly finished on the loo. Sometimes, a prolapse can mean that you feel the need to go for a pee less often during the day but seem to need to go more often during the night.

What can be done for this common problem?

Not all prolapses get worse over time, so it may be that you don’t need to do anything apart from taking care not to do things that are likely to make the symptoms worse – heavy lifting, putting on too much weight, getting constipated and straining on the loo.
Sometimes an operation is advised, to try and lift the vaginal wall back into place. This might include having a hysterectomy.
There are non-surgical options which include exercising your pelvic floor muscles to be stronger to help lift the fallen walls back up. Your pelvic floor muscles are slung from the front to the back of your pelvis and just like your other muscles need to be exercised – ‘use it or lose it’. These muscles help keep your back passage and bladder closed to stop leakage of urine or wind or poo. But also help support the vagina and back passage.

You might also be offered a pessary.
What is a pessary?
A pessary is a synthetic device usually made of silicone which is positioned inside the vagina to help support the walls or uterus and lift them back into place. Usually a doctor will fit the pessary, which  might  take a few attempts to get the sizing right,  and it will stay in for 3-6 months before it gets checked and replaced. You can keep using a pessary as long as there are no problems with it. A pessary is not: ‘just for the elderly’, ‘not suitable for those who want an operation’, ‘a last resort option’, but using a pessary does require follow up care to make sure that it remains correctly fitted and right for you.
 So let’s talk about prolapse
 The first thing to be clear about is that bladder and bowel problems aren’t an automatic consequence of having children or ageing – yes more likely- but not to be assumed. So don’t accept ‘well you’ve had children’ or ‘at your age……’ Instead you need to work out what you might feel ok saying to your doctor, family, partner, friends without feeling ashamed or embarrassed.
How about:
I am having a problem with my bladder and can’t empty properly, or need to return to the loo soon after I have been
I can feel a heaviness vaginally (or ‘down below’ if that seems easier) which is making me uncomfortable
I am not constipated, but can’t empty my bowel properly which leaves me feeling uncomfortable
I am aware of a bulge protruding out when I wipe myself after being to the toilet
I can feel something coming down, particularly after I have had the grandchildren for a day, or have had a long day on my feet.

Then you need to ask how best to find out exactly what the problem is and what treatments are available to help things to feel better. Your doctor should refer you to see a specialist in the hospital for further assessment and to give you access to specialist physiotherapists or nurses who can help.

My research is to try to find out what questions women and clinicians have about pessary use for prolapse and have a survey open until January 2017. If you would like to take part, click on this link:

The questions will all be included in a process to find the top ten priorities for future research.
What words do you use to talk about this subject?

Monday, 17 October 2016

Menopause: What does it mean?

All women become menopausal at some stage. Natural menopause is due to the ovaries gradually running out of egg cells and being unable to produce the usual cyclical production of oestrogen and progesterone. With changing balance of these hormones, the stimulation of the womb lining changes and so periods may become irregular and heavy. This changing phase, known as the perimenopause, can last for a few years until finally the ovarian hormone production is so low that the womb lining is not stimulated and periods stop, the time of the menopause. The resultant low level of oestrogen can produce a range of symptoms such as flushes, sweats, low mood, joint aches, disturbed sleep, and also some later consequences on vaginal, bladder, bone and heart health. The severity, duration and impact of symptoms and later health effects varies hugely between women, and hence the need for treatment is very individual.
Natural menopause usually takes place around the age of 51. However, for some women menopause can occur at a younger age and may be the result of treatment for another condition. When menopause occurs early after cancer treatment, it may seem like the last straw. Women may be unprepared for the onset of menopausal symptoms when they are also dealing with the devastating effects of diagnosis and treatment, and indeed may not initially realise what is happening.
The importance of provision of information before treatment which may lead to an early menopausewas recognised in the recent NICE guideline on diagnosis and management of the menopause which recommends that healthcare professionals should:
  • Offer women who are likely to go through menopause as a result of medical or surgical treatment (including women with cancer, at high risk of hormone sensitive cancer or having gynaecological surgery) support and:
                    - information about menopause and fertility before they have their treatment
                    - referral to a healthcare professional with expertise in menopause
For women who have had treatment for cervical cancer, the type of treatment will determine whether or not the treatment will lead to early menopause. A hysterectomy may be performed and the ovaries may be able to be conserved. The ovarian function may then continue until they naturally stop working, but of course having a hysterectomy stops any periods and so it may be difficult to know whether or not the ovaries are still working. In this situation it is important to know what signs and symptoms to look out for.
If the ovaries are removed at the time of surgery, or are exposed to radiotherapy or chemotherapy, then menopause can happen suddenly. This sudden drop in oestrogen can lead to rapid onset of menopausal symptoms for which earlier preparation with provision of information is essential.
Whether treatment for cervical cancer leads to an early menopause, or women subsequently experience menopause at the usual age, treatment options need to be considered. The main reason to consider treatments is for symptom control. Symptoms affect around 80% of women but in varying degrees and not all require treatment. Diet and lifestyle measures can be the first step, with losing weight, stopping smoking, and reducing alcohol and caffeine being helpful both for symptom control and for later health benefits.
The most effective treatment for the effects of oestrogen lack is to replace oestrogen in the form of Hormone Replacement Therapy (HRT). HRT is recommended for women with troublesome menopausal symptoms, but is also recommended in women who experience a premature, (before age of 40) or early, (before age of 45) menopause, even if they do experience symptoms since HRT offers long term heart and bone health benefits. In this situation, HRT should be continued at least until the average age of the menopause.
Many women have concerns about taking HRT after much publicity in recent years about risks, but the current view is that for most women, the benefits outweigh the small risks. Having had cervical cancer does not mean that HRT should be avoided, there being no known association between HRT use and risk of cervical cancer. The type of HRT taken will depend on the treatment, such as whether or not a hysterectomy has been performed. Particular attention should be given to vaginal health, particularly if radiotherapy has been required. In this situation, vaginal oestrogen may be required in addition to HRT to help maintain vaginal health and prevent dryness and thinning of the vaginal skin.
It is sincerely hoped that with better education and understanding, the unwanted additional effects of treatment for cervical cancer can be reduced by appropriate preparation and treatment.
Further resources:

Tuesday, 5 July 2016

What's in a Name?

What’s in a name?

When considering effects of the menopause, hot flushes and sweats regularly come top of the list of expected symptoms. Increasingly though, women and healthcare professionals are becoming aware of other symptoms due to declining and low levels of estrogen following natural decline in ovarian function, ovaries affected by other treatments, or removal of the ovaries. 

These may include sleep disturbance, low mood and joint aches. However, there is still a low level of awareness of the effects of estrogen lack on the vagina, bladder and pelvic floor, effects which can cause significant discomfort and distress yet still are hugely under reported and under treated.

To address this issue, let’s start with the name. Many terms have been used including, vaginal dryness (to demonstrate a common symptom), vaginal atrophy (to indicate thinning changes of the vagina), vulvovaginal atrophy (to include thinning effects also of the vulva or “outer lips”), urogenital atrophy (to indicate that the urological system, ie bladder, can also be affected), and, the most recently recommended term—Genitourinary Syndrome of the Menopause (GSM).

None of these roll easily off the tongue, which is indeed part of the problem. Women often find it very difficult and embarrassing to discuss gynaecological issues, especially related to the vulva and vagina and confusing terminology does not help.

Whatever we choose to call the vulva and vagina, we need to recognise that the lack of estrogen can have significant and sometimes devastating effects on this very personal, sensitive area. In fact, it is thought that up to 50% of all postmenopausal women can experience symptoms due to GSM. However, it is believed that the true number of women affected is unknown since many women do not report symptoms and so this figure is likely to be an underestimate.
Symptoms can include dryness, pain during sexual intercourse, irritation and itching, susceptibility to vaginal infection and also bladder symptoms such as urgency to pass urine, passing urine more often and urinary tract infections.

Vaginal dryness, irritation and pain during sexual intercourse are due to estrogen lack affecting vaginal and vulval blood supply, lubrication, loss of elasticity and thinning and inflammation of the vaginal walls and vulval skin with reduced sensation and response. Not surprisingly, these changes often lead to reduced interest in sex. In addition, estrogen helps to maintain vaginal acidity by facilitating production of lactic acid from lactobacilli (normal vaginal organisms). An acidic vaginal environment is a good barrier to infection. With less estrogen, vaginal acidity changes and both vaginal and urinary infection risk is increased. Bladder symptoms are due to estrogen lack on bladder muscle contractions; estrogen is thought to play a role in regulating bladder and urethral muscle contractions so that estrogen lack can lead to increased muscle contractions and feeling of urgently needing to pass urine. Further, there has been recent increased interest in the effect of estrogen on support of the pelvic floor. With low estrogen levels, pelvic floor support is reduced leading to dragging sensation and even prolapse.

It has been recognised that GSM, particularly the vulval and vaginal symptoms, can have significant impact on quality of life and relationships. Previous surveys from our Menopause Matters website visitors have shown that women often feel that these symptoms had a negative effect on their confidence, self-esteem, and relationships and many made excuses not to have sex because of the discomfort.

These symptoms often become noticeable a few years after periods have stopped, or a few years after stopping Hormone Replacement Therapy (HRT). This apparent delay in these effects appearing is due to the fact that estrogen lack on the vulva, vagina and bladder generally takes a few years to become evident, in contrast to the flushes, sweats, low mood and joint aches which are triggered early in the stage of falling and low estrogen levels.
The other important difference between urogenital symptoms and flushes and sweats is in relation to duration; while flushes and sweats can last many years, for many women they do reduce with time but urogenital symptoms do not reduce. Indeed, these symptoms gradually worsen with time and so any treatment needs to be continued long term. This message was confirmed by the recently published NICE guideline on Diagnosis and Management of the Menopause, recommending that “Treatment should be started early before irreversible changes have occurred and needs to be continued to maintain benefits” (NICE guideline. Menopause:diagnosis and management.)

For such a common consequence of the menopause which can have significant effects, it is clear that effective treatment is required, should be started early, and continued long term, perhaps even indefinitely. Before discussing which treatments are available, it is worth emphasising the need for women to be aware of this consequence, to look out for early signs and to feel able to seek help and treatment. Hopefully the wide distribution of this magazine, along with the popularity of our website and increasing use of social media will help more women to access this information.

Regarding treatment options, vaginal estrogen has been shown to be able to reverse the changes of estrogen lack and significantly reduce symptoms. For women in whom symptoms of GSM are the predominant effect of the menopause, vaginal estrogen alone can be offered and is recommended in the NICE guideline. Vaginal estrogen needs to be prescribed and can be taken in the form of a small vaginal tablet inserted using an applicator, a vaginal cream which can also be applied to the vulval area, or a vaginal ring. Personal preference, dexterity and discussion of symptoms should lead to individualisation when choosing which type to use.

Vaginal estrogen is not the same as taking HRT; HRT replaces estrogen throughout the body and is taken by a tablet, patch or gel. Vaginal estrogen is concentrated in the vagina and bladder and is minimally absorbed throughout the body. This major difference means that vaginal estrogen will not control symptoms such as flushes and sweats (systemic symptoms) nor have any effect on bone or heart health, unlike HRT. It also means that women who may have concerns about taking HRT because of past medical history, can often still use vaginal estrogen. 

Women who take HRT for systemic symptoms may find that the HRT also helps GSM, but in some, while systemic symptoms may be controlled, vaginal estrogen may be needed in addition to reduce vaginal and bladder symptoms. This need for both HRT and vaginal estrogen may be increasing as lower doses of HRT are now often used. Regarding duration of treatment, many women stop treatment after a few weeks if they have not noticed a benefit, or after a few months if symptoms have reduced assuming that the problem has been cured. It is important to understand that vaginal estrogen needs to be used for a few months before full benefit can be realised, especially if significant changes are already present when treatment is started. Also, symptoms do often return after treatment is stopped and so continuing treatment is recommended.

For many women, the use of vaginal lubricants and moisturisers can help the dryness and reduce discomfort. While these do not correct the cause ie estrogen deficiency, they may be preferred for women with mild to moderate vaginal dryness or for those who do not wish to use vaginal estrogen. The value of moisturisers and lubricants was confirmed in the NICE guideline which states “..women with vaginal dryness..moisturisers and lubricants can be used alone or in addition to vaginal estrogen”.

Many types of both lubricants and moisturisers are available and knowing which to choose can be very difficult. Lubricants provide a rapid effect and are applied just before sex. They can be particularly helpful for women who experience discomfort only during sex due to dryness. Lubricants are available as water, silicone, mineral oil or plant oil based.

Moisturisers are applied more regularly such as daily or every two to three days. They rehydrate the vagina and maintain the moisture for two to three days. The longer lasting effect may be helpful for women who experience discomfort not just during sex. Moisturisers mostly contain water but different products vary in the content of other ingredients.
When choosing a moisturiser or lubricant, the pH (acidity) and osmolality (measure of concentration of chemical particles) should be considered. Many commercially available products show a high osmolality which may cause tissue irritation. It is recommended that products with pH which most closely resemble healthy vaginal pH of 3.8 to 4.5, and with low osmolality are preferred.

If lubricants are used as well as vaginal estrogen, they should be used at different times of the day since estrogen absorption may be reduced if used immediately after a lubricant. In addition regarding timing, it is recommended not to have sexual intercourse immediately after applying vaginal estrogen since absorption by the partner may occur; wait at least one hour.

It can be difficult to talk about sex and vaginas, but maintaining vaginal and vulval health after the menopause is essential. It’s time to speak up, whatever name we choose to use!

Monday, 4 April 2016

HRT and breast cancer.

HRT and breast cancer.

When considering the use of Hormone Replacement Therapy for treating menopausal symptoms, many women and healthcare professionals have been strongly influenced by the risk of breast cancer thought to be associated with the use of HRT. Previous publications have strongly emphasised the risk and headlines such as “HRT doubles risk of breast cancer” has understandably had an impact. In many cases, this concern has led to women choosing to tolerate menopausal symptoms, which, at times, can be severe, and to healthcare professionals refusing to prescribe HRT or advising women to stop HRT unnecessarily. While no medication is entirely without risk, it is essential that risk is kept in perspective and that there is a clear understanding of the balance between benefits and risks.
Breast cancer is the most common cancer affecting women in the UK with just over 50,000 diagnoses in 2011, equating to around 155 per 100,000 women per year. However it is not the leading cause of death in women, many more women dying each year from cardiovascular disease and dementia. The baseline risk for breast cancer for women around the age of menopause in the UK is around 23 cases per 1000 women, but each woman’s risk will vary according to her history, family history, and in relation to some modifiable risk factors. While the association between HRT and risk of breast cancer is well known and often exaggerated and misunderstood, the risk from other modifiable factors is often unknown and ignored.
The recent NICE guideline on diagnosis and management of menopause included a section on breast cancer as part of the section on Long-term benefits and risks of hormone replacement therapy. Over the years many individual publications have shown varying levels of risk, with some showing no increase in breast cancer and others showing an alarming increase. Each publication has received varying levels of publicity leading to widespread confusion. The NICE guideline development group have closely examined all publications not only for their findings but also for the quality of the study. The result is an unquestionable authoritative document which supports both women and healthcare professionals to make informed choices about menopause management and use of HRT.
So what does NICE say? The first important point is that the levels of risk were reported as absolute figures rather than percentage or relative risk. This may seem an academic point but in fact how risk is reported can have a huge impact on how risk is perceived. For example, a risk being reported as “doubled” or “100% increase” sounds much more alarming than if the absolute rise was an increase from 1 case per 1000 to 2 cases per 1000. Sadly alarmist headlines rarely report absolute figures. The reporting of the Women’s Health Initiative trial in 2002 was an example of the use of percentage increases which led to dramatic loss of confidence in the use of HRT despite the fact that absolute risks were very small.
Secondly, NICE clearly describes different effect from different types of HRT. The purpose of HRT is to replace estrogen since it is the declining and low level of estrogen that is believed to cause the consequences of the menopause in terms of menopausal symptoms and later health effects. Women who have had a hysterectomy can generally take estrogen only HRT while women who have an intact uterus need to take progestogen along with the estrogen (combined HRT) to prevent estrogenic stimulation of the uterine lining. It has been suggested for some time that estrogen only is not associated with the same level of risk of breast cancer as combined HRT but there has been a lack of awareness of this difference, many young women who have had a hysterectomy stopping estrogen early or being advised to do so. NICE confirms that HRT with estrogen alone is associated with little or no change in the incidence of breast cancer. The absolute figure given is for 4 fewer cases of breast cancer in women taking estrogen only HRT per 1000 menopausal women over 7.5 years, based on baseline risk for that group being 22.48 per 1000.
For women who take combined HRT, NICE confirms that this can be associated with an increase in the incidence of breast cancer. The absolute figure given is 5 more cases of breast cancer in women taking combined HRT per 1000 menopausal women over 7.5 years, baseline risk as noted. This increase in risk appears to be associated with the length of time that HRT is taken, the risk being higher when combined HRT is used for more than 4 years. However, the risk reduces and returns to each woman’s baseline risk after HRT is stopped. Another important point highlighted is that the mortality from breast cancer does not appear to be increased compared to women who develop breast cancer and are not taking HRT. The conclusion from these two points is that combined HRT may, in a small number of women, stimulate the growth of cancer cells which are already present, rather than cause breast cells to turn into cancer, and the natural history of disease for each woman is not altered.
The NICE group did examine whether different types or routes of HRT affect risk. With the knowledge that estrogen only seems to be less likely to affect risk than combined HRT, it has been suggested that certain types of progestogen may also differ in association with risk. NICE concluded that the evidence was not yet strong enough to recommend that certain types of progestogen were better than others. It has been recommended that further research be carried out to determine if there are differences in risk between different types of progestogen within combined HRT so that preparations can be offered which maximise benefits and minimise risk.
While any diagnosis of breast cancer is devastating, it is really important to fully understand the role of HRT, that any risk is small, the risk returns to baseline when HRT is stopped, that each woman’s risk of dying from breast cancer is not affected by the use of HRT and that each woman should take this into consideration along with the benefits of HRT for her.
It has been known for some time that there are other factors which affect breast cancer risk and the table shows that being overweight, having first birth after age 31, and regular alcohol are all associated with higher level of extra cases of breast cancer than the use of combined HRT. Further, regular physical activity is associated with reduced risk. Therefore, the decision around use of HRT and consideration around health benefits and risk should also take into account other factors, particularly weight, which can be addressed.
Finally, concern and confusion often arises around the options for treatment of menopausal symptoms in women who have had breast cancer, or who may be thought to be at high risk for breast cancer, for example due to strong family history. Menopause may occur as part of the treatment for breast cancer when it may lead to premature menopause, or may occur naturally regardless of treatment. The NICE guideline recommends that women should be given information about all available treatment options. These include non-hormonal treatments such as the antidepressants, Selective serotonin reuptake inhibitors (SSRIs) which have often been used in this situation to reduce hot flushes and sweats due to the serotonin action. However the guideline emphasises that paroxetine and fluoxetine should not be offered to women who are taking tamoxifen for breast cancer treatment since interactions with medication may occur leading to the tamoxifen being less effective.
NICE also reviewed the role of Alternative therapies for women in this situation and concluded that while there is some evidence that St John’s Wort may be helpful for reducing menopausal symptoms, women should be aware that there is lack of clarity about appropriate doses, there may be variation in preparations and that it may interact with other medications including tamoxifen. Further research has been called for to examine the effectiveness and safety for treatments for menopausal symptoms in women who have had breast cancer.
Referral to a healthcare professional who is a menopause specialist is often required for women who have had, or are at high risk for breast cancer.

Overall, the association of breast cancer risk with use of HRT does cause concern to many women and healthcare professionals but the NICE guideline provides clear information and goes a long way in putting the small risk in perspective. Work is still required to understand which treatments can be safely offered to women who have had breast cancer.