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Right. I am just here facilitating. Really, it's Vikram has got the knowledge in the brains. So I'm gonna hand over straight across to VRA. We will do questions at the end. But if they come into your head, put them in the chat and then we can, we are go back through the chat um and we'll cover them off, but always likes a lot of questions because from what we can present in this period of time, he's got to kind of guess in some ways what it is that wants to be discussed and what you're going to have questions about. So do put questions in, there's no fit questions, put anything in there that you think would be useful to your clinical practice. Uh I'm gonna go on mute and uh hand over to yourself. Thank you. Thank you. Thank you so much, Becky. As always for that quick introduction, uh I'm gonna share my slide so that we um dive straight in uh and hopefully run through them very quickly. Let's go to F one takes a, a few seconds. Hopefully you'll be able to see the presentation. Uh OK. OK. There you go. Can you see my slides. Becky. Yeah. Yeah, I can do. Yeah, if you want to. Yeah, perfect. So, I think it's a little bit slow tonight, but it's, yes, it does a bit slow, but hopefully it's not too many slides, so we should get through that. Yeah. All right. Yeah, no problem. All right. So, welcome everyone again. My name is Vikram. I work at UCL H uh, and I also work at 10 Harley Street. Uh I'm a BMS certified menopause specialist. So, hopefully, I'll give you a little bit of uh uh basic knowledge about uh genitourinary syndrome of menopause. Many of you will already be familiar with this uh and actually seeing patients treating them. Uh So hopefully, I won't repeat too many things and we'll go straight after that for question and answers. Why are we talking about GSM genitourinary syndrome of menopause? Uh because we know it's a chronic, it's a progressive condition because of lack of estrogen and the androgens. And that happens during menopausal transition. Uh It used to be called as vulvovaginal atrophy or vaginal atrophy on its own. But because so many tissues in the pelvic area are affected, not just the vulva, the vagina, but the bladder and the pelvic muscle. The overall name was changed to genitourinary syndrome of menopause. Now, of course, therefore, it affects all urogenital tissues. It's vulva vagina, bladder, urethra, pelvic floor muscles and the symptoms may not be apparent for several years after menopause. So often we talk a lot about hot flashes, night sweats, difficulty sleeping joint pains, mood changes and GSM may not be right there on the top of the list for many women because it may take time for the lack of estrogen, the lack of androgen to show up as vulvovaginal or genitourinary syndrome or symptoms way down the line. Many months or years after the menopause transition happens, it's often underdiagnosed uh and it's undertreated. Uh about 60% of postmenopausal women who are not using any systemic HRT uh and just going about uh monitoring their symptoms or addressing them through lifestyle or non hormonal uh interventions, they could suffer from symptoms of GSM. Often women will be embarrassed to talk about it in the clinic and unless you try to find out more yourself and ask questions which can be suggestive. Many women may not be forthcoming with genital urinary symptoms. That is why it often remains underdiagnosed and undertreated. It generally takes about 3 to 5 years. Again, this is not absolute. Uh Some women may present earlier, others may even take longer but generally 3 to 5 years of constant lack of estrogen for most changes to become apparent and symptoms to become quite bothersome. Now, women who are taking systemic HRT either oral tablets or patches, gels, capsules, they may still experience symptoms of urogenital atrophy. So about one in four women who are using systemic HRT in various forms can still have vaginal dryness, still have dyspareunia and one in 4 may still need the extravaginal estrogen in a healthy vagina. Uh what happen normally as part of physiology is there are lots of superficial mucosal cells, superficial skin cells approximately every 4 to 6 hours. And of course, these cells are aging large amounts of glycogen healthy bacteria. The lacto basil once there is estrogen, partly androgen deficiency, this will cause the mucosa to become quite thin and the superficial cells go away, the skin becomes exposed. There's a reduction in those cells and the glycogen that results from them. So the lacto Basili will decrease other bacteria may gain uh dominance and there is a slow rise in ph of vaginal secretion. So normally ph being around four will keep increasing and all those changes can often then cause the symptoms. The d the dryness, the the tearing of the skin, the reduced vaginal elasticity because of changes to the elastin fibers which support the skin. And you can see on the right hand side, that's the difference in terms of microscopically how the skin looks. You. On the left hand side, you have the lots of superficial cells uh which become much, much less on the right hand side, the skin becomes very thin, the parabasal of the underlying cells get exposed and that's why the symptoms happen. What are the symptoms? Uh The typical ones are some sort of vaginal discharge and this discharge may be different from the discharge and ovulation, a bit of kind of watery or a serious uh or a blood stain discharge may happen. Vulval, vaginal dryness, uh dryness, burning, itching, irritation, different ways in which which this is described dysuria, painful sex. Uh and that often has an impact on arousal, orgasm, uh vaginal bleeding, tearing of the tissue uh cannot tolerate, smears cannot tolerate speculum, uh prolapse can worsen urinary urgency or incontinence. Both can present at this time. Urinary infections become frequent. Uh So some women may simply present with recurrent UTIs during menopausal transition or other times when they have low estrogen. And that may be the first sign. Sometimes that the estrogen lack is starting to impact the urogenital tissues. Tissue shrinkage can of often be bothersome. Um So there's thinning of labia, there's growing of enteritis uh and that this can stop people from doing day to day activity. So they are unable to wear certain types of clothes. For example, jeans, they may be avoiding cycling or physical activity. They will avoid sex. This will have a bearing on their relationship. They cannot sit for long periods of time when there are too many symptoms. And of course, they may avoid having important examinations such as cervical smears because of the pain and the discomfort. So it's a really important issue uh easily solvable in most situations, but just need to ask patients uh if they have these symptoms, science wise, uh again, often the diagnosis is clinical and history is usually very classical. But if you were to examine the patient and this is important because sometimes uh improvement may not happen with vaginal estrogen. And to assume that this could only be vaginal atrophy, you may miss the vulval, vaginal other conditions or skin conditions or dermatosis. So, it's really important to confirm diagnosis. Rule out other vulval conditions like lichen sclerosis and the signs to look for atrophy is mainly the changes in tissue color. It becomes pale, uh it appears inflamed there, there may be bleeding with insertion of speculum. Uh often you find that the rugae of the vagina may be lost. So you have a pale smooth uh skin, the fissures may be there, tears may be there and of course shortening of the vagina difficulty inserting speculum will often make it obvious the urethra may become more prominent and the fat content of the labia majora of course will be reduced. Thinning of labia is is common. Labia morra can be resolved or fused in extreme cases of atrophy. And this will often then lead to loss of clitoris from view or exposure. So all those are typically shrinkage and the uh loss of tissue uh um smoothness or or sort of shine is usually what you will see when you do a speculum examination treatment. Uh it should be started early. So, if you clinically suspect there is vaginal atrophy, the woman presents with you with typical symptoms do not delay treatment, start treatment straight away. Usually it takes 3 to 4 months for the improvement to happen. Uh and us persist with the treatment. So sometimes the expectation is you give a treatment for vaginal atrophy. Often things will improve within a couple of weeks that may not happen for some women. In fact, for majority, it usually takes 3 to 4 months for the optimum treatment efficacy and the and severely affected women may take longer to respond. So, if they've had a long duration, years of estrogen lack, that has caused the changes for vaginal atrophy, uh go on for a long period of time, they will actually need quite long to respond. And how long do you treat vaginal estrogen is so little absorbed in the body. It has no risks in terms of long term risk. You can continue with the treatment indefinitely. As long as the woman is symptomatic. As long as you have some kind of a review. Once a year or once a couple of years, it's a local treatment. Uh And if there are no systemic menopausal symptoms, it's only urogenital symptoms, then you're only going to give local uh treatments. The current treatment preparations, which we commonly used in the clinic, uh of course, are very low dose and so very little amount of estrogen. If at all is absorbed in the blood and the progesterone treatment therefore, is not required for endometrial protection. If you're only using local vaginal preparations. And the what type of treatment method you use? Whether it's pessaries creams or ring uh will of course depend on patient preference as well. Some women will prefer to use the pessaries while other may like the ring or the cream. What are the treatment symptoms of non hormonal treatments? Of course, lifestyle modification does have some role. Uh So stopping smoking has been shown to improve symptoms, regular sexual activity, improve symptoms. Sedentary lifestyle can increase symptoms. So, uh avoid sedentary lifestyle and active uh lifestyle is important, washing vulvovaginal area with water, avoiding any artificial or perfumed products. This is important again because these products themselves can cause soreness and irritation. Uh and so therefore, avoiding any artificial products is really important, specialist pelvic floor physiotherapy. And I'm mentioning this here because it's really important that there may be associated issues such as vaginismus. So there's an hypertonicity of the pelvic floor muscle that can contribute to the vaginal atrophy or genitourinary syndrome symptoms. And often the pain uh forms a part of the reflex uh where the muscles get involved. And therefore, pelvic floor physiotherapy has a major role and and there are pelvic floor physios available in most hospitals. So, referral would be important while you're trying to address the uh atrophy symptoms just with estrogen or non estrogen treatments in women who have say uh significant shrinkage vaginal dilators can be used alongside non hormonal or hormonal treatments uh to improve the uh the dilation of the vagina and the vaginal health in terms of nonhormonal lubricants, moisturizers. Uh So these can be used in conjunction with vaginal estrogen therapy. If you're choosing a product, it's very difficult to choose it from over the counter. Uh patients often um will not have much information about the PH or the contents of these lubricants or moisturizer. If it is possible to look at it, then we like to have a ph close to four. That's a physiological ph. Uh The ones I recommend tend to be yes or sutil uh because the other scan uh may contain a nonphysiological ph or could irritate uh because of the contents in their packaging. The lubricants are mainly for short term relief. Uh This could be water, oil or silicone based. Again, there are different ones you get over the counter in the pharmacy, but they are used at the time of sexual activity. Oil based lubricants can weaken condoms. So that's something that keep in mind for perimenopausal women moisturizers are are long term. So they are usually used twice a week. Uh and then they affect the fluid content of the skin epithelium and they replace some of the normal vaginal secretion. Ideally again, as I said, the osmolality, the ph try and make it as close to physiology as possible. Uh And often, uh uh again, I tend to recommend yes or sutil, these are the two products I often uh trust, treatment wise, vaginal estrogen. Uh It can be used as long as it needed. Uh It enhances blood flow. It restores the cell maturation. It replaces the healthy bacterial flora drives the ph below five and therefore, restores vaginal health. It has been shown to also improve bladder urgency, incontinence, bladder frequency, nocturia. Estradiol is the most commonly used one. It's available as estradiol. Uh either vaginal tablets, pessaries or ring. Uh You have a weaker estrogen called estriol, which can be available as a cream or a pessary or an oily gel. Uh uh It's a loading dose. Usually it's once every night for two weeks and then you can often go for a maintenance dose of a preparation like a pessary or a cream twice a week. You can use it even following treatment of breast cancer. So, women who had breast cancer can often be denied hormones if they have hormone sensitive cancer. Uh However, if it's severe vaginal atrophy symptoms and the moisturizers or lubricants have not helped, they can take vaginal estrogen if they're on tamoxifen. That's straightforward if they're on aromatase inhibitors like letrozole and estro or others. Um There's, it's, it's recommended that if possible change the treatment to tamoxifen and then have vaginal estrogen. Uh at the moment. BM S doesn't recommend it with uh aromatase inhibitors. And that's because some observational data suggest that there is a small increased risk of recurrence if you look at the American College guidelines they say that individualize and it can be offered even if the woman is on aromatase inhibitors. As the last option. If the non hormonal treatments have not worked and you can individualize based on the patient. Other treatments are available, you have vaginal dehydroepiandrosterone DHEA. This is available as an Intrarosa pessary once daily. Uh not in NHS widely used. It's mainly available in the private sector and DHEA is basically is an adrenal gland product and ovaries also produce it. It's got both androgenic estrogenic sort of action. Uh It's available as plaster uh and it's delibus DHEA vaginally every day in the vagina, DHEA converts to estrogen and androgen by enzymes within the epithelium and it doesn't affect the endometrium. And so, of course, it does the maturation of the parabasal cells into superficial cell increases the collagen and it start to improve the vaginal symptoms at the moment. It's not licensed or it's not been tried widely in women with breast cancer. But there is an indication that this may be probably the first line preparation for women who can't take vaginal estrogen because it's a local effect of estrogen and androgen in the vaginal mucosa rather than the vaginal estrogen alone. Apamine uh is a selective estrogen receptor modulator. This is oral medication can be used for vulvovaginal atrophy given a 60 mg once a day. Again, helps with a lot of vaginal symptoms. It's got again, antagonistic effect on endometrium and breast. So that's useful. It may be used in women with history of breast cancer or endometrial cancer. But remember there is no clinical trial data. It's not yet been tried in this group of women, but it may be one of the options if we have more data for women with hormone sensitive cancer. In future, one of the main side effects of apamine being a receptor modulator is it can cause some hot flushes and it should not be used in women who are at risk of deep vein thrombosis. Finally, if hormonal nonhormonal treatments, uh medical treatments uh have not worked. Some women may choose to have the laser therapy. So local treatments such as vaginal laser, uh it's thought to improve blood supply to the epithelium. And there are two different types of lasers which are commercially available. Uh for both the treatment is delivered every 4 to 6 weeks and then often you have repeat treatments every year. The side effects can happen. Uh changes to menstrual cycle for perimenopausal women or discharge or some sort of urinary leakage has been reported right now. The quality of the trials which have assessed this treatment is poor. And of course, there hasn't been overwhelming evidence in support of the treatment uh and randomized trials, for example, do not suggest that there is good quality evidence for this particular treatment. So I don't recommend it to my patients. Hopefully more clinical trials, better clinical data in future might suggest this is an option for those who do not want to have hormonal treatments. It remains to be seen. Um And so at the moment, it's quite expensive as well. So, uh let's see what happens in the future. So that's a N in, in a nutshell, the summary of what happens with vulvovaginal atrophy. And um that's it from my side. So I'm gonna stop sharing my slides and I think we'll have plenty of time for questions. Brilliant. Thank you very much. Vi um Yeah, we've got a question here already from Emily. Um Emily's asking, do you recommend high hylafem uh moisturizer with Hyaluronic acid? It's a recent study shown that it was effective as a vaginal estrogen. Yes. Um So again, hylafem would be a non hormonal option. Uh II, haven't seen a direct good quality comparative data comparing it to vaginal estrogen. Uh But it's a very good form of uh nonhormonal uh moisturizer lubricant uh category of uh uh of, of medication, you could say, uh I certainly uh patients who are on it like it and, and I uh encourage them to continue. Um So that would be one of the other ones besides the yes and the sutil that I often recommend. Great. OK. And has anyone else got any questions in the audience? We've got what? 45 people joined us tonight. So, is there anything anything else that victims maybe touched on that, that you'd like some more information on or or is there anything specific that you, that you want to want to ask the recording is available obviously to go back to? So there was a lot, lot of sort of information in there as well. Um Thank you, Emily, I'm not sure how much is delayed in this feed at the moment because of uh because of the sort of a little bit of drug we had on. Uh OK. Can vaginal estrogen be continued for more than a year? Yes, you can continue vaginal estrogen as long as needed. Uh There's no upper limit as to when you stop. Uh most women will use it for a few years then attempt to stop it. Uh because they want to see if their symptoms recur if the symptoms come back. Of course, you continue using as long as you have symptoms and that's why I said indefinitely. Uh unless the woman comes off takes a break and doesn't have symptoms, then that's fine. Uh But otherwise because of chronic progressive condition, if the vaginal, because I sensitive to lack of estrogen, you usually need a, a long term use of these medications, not a short term use. Well, thank you. Thanks. I it. So now Katie is asking, can symptoms start during menopause? Yes. So many women will start having these symptoms earlier during perimenopause even though they're having periods and they are bleeding and the times when the estrogen runs slow, they start noticing vaginal dryness and of course, once menopause happens, periods have stopped estrogen levels are really low. That's when the symptoms become more apparent. It may take a couple of years after the last period to really start noticing the symptoms. But they can happen at any stage. It's very individualized. In fact, they may even happen for many women when they breastfeed, they have low estrogen levels or even at the time of periods when they are well into their twenties, thirties, forties and have a drop in estrogen around period. Number of women may be very sensitive and, and experience vaginal dryness even then. So when they reach menopause and they're very sensitive, that's when they really start feeling the the vaginal symptoms again. Brill. Thank you. Ok. And Kayleigh's asking estradiol maintenance dose, can this be increased to three times weekly? Yes, it can be. Uh so again, licensed dose is twice a week for maintenance. But if you have a patient who feels that uh there are still persistent symptoms, residual symptoms which are not being taken care of, I tend to often give a trial of three times a week for six months and then again, try to go back to a maintenance dose and for many that will work. Uh long term use of unlicensed dose that's not been tried. There are no proper studies or long term data about continuing to use higher than licensed doses for 234 years, probably harmless. Uh But again, one would want to return to a licensed dose after the initial treatments improve or combine nonhormonal with hormonal medication rather than using off license too frequent uh hormonal medication. Well, thanks Lindsay's asking. Can you explain again which breast cancer patient, which breast cancer patients should avoid? Ok. So if we go by the BMS recommendation in the UK, we say that if you've had breast cancer treatment, then the first line treatment for any vaginal atrophy or GSM symptoms is non hormonal. So your moisturizers, your lubricants uh lifestyle, all that comes first. If that takes care of symptoms, then that's fine. Many women will find that doesn't take care of all symptoms. The symptoms can worsen. Then of course, you can choose a vaginal estrogen. Uh The trend now is to use the estriol or the d uh DHEA first and then go for estradiol. But in principle, vaginal estrogen can be used. If you are on adjuvant therapy, say you are taking tamoxifen, then of course, it's completely fine to use any form of vaginal estrogen. If you had a receptor negative tumor, and you're not on adjuvant therapy, again, you can safely use any form of vaginal estrogen. The question comes is only if you're on aromatase inhibitor. So your classification, the grade of the tumor, the prognosis of the cancer suggested that you should be on letrozole. And there are some recent observational data which suggest small possible increased risk of recurrence. Even with that little bit of vaginal estrogen. Now, these are observational studies and often they have lots of confounding and biasing factors. So they're not gold standard evidence like the randomized study, which is why we take everything with a pinch of salt if we can avoid, if we can get you to tamoxifen instead of letrozole and then give vaginal estrogen. That would be the best way forward. But if that's not possible and you're really having terrible symptoms, I tend to individualize. And after having discussed the risk, I tend to still prescribe uh estrogen uh with an aromatase inhibitor. A tiny 10 mcg dose. I've tried to audit my practice do serum estrogen levels just as an observational whether how much estrogen is absorbed from vaginal estrogen. And in my group of patients, I've never picked up any significant estrogen in the blood at all. It's always been less than detectable levels. So that is a bit of reassurance to say there's not much entering your circulation. So that's where we are in UK with the vaginal estrogen with breast cancer. Brilliant. Thank you. Um Kelly again is asking can both cream and vaginyl estradiol be used together? Um you could use it. So for example, if you're using it more often, uh as I said before, a short trial of maybe three times a week uh of the estrogen rather than twice weekly maintenance dose, then you can use together, you can give one day of a cream and two days of capacity in the week. One of the advantages of the cream. And again, this is off license is if there's a lot of vulval atrophy, vulval dryness, you can take a tiny bit of cream on your fingertip and apply locally to the vulval area there that often helps patients. Uh but there's a lot of vulval dryness and so you can always combine the cream with the pessary in that sort of a manner that should be fine. Great. Ok. And Debbie's asking next question, sorry, Debbie's asking, would you recommend the vaginal estrogen if the urinary problems alone, do you recommend this before trying tablets for urge incontinence? It's, it's part of uh sort of looking at clinically why that uh urinary symptom has developed if your urinary symptoms have developed as part of your menopausal transition. If you think the pelvic floor is weak, if we think that it's all sort of other, other menopausal symptoms are happening along with the the bladder frequency. We don't think anything structural issue that with any other cause that may have caused it. I would certainly always go for vaginal estrogen as one of the first options because that often will mean that you have given it a good fair chance before you think whether your symptoms improve or not or have further interventions medically or surgically. Well, thank you, Christine is asking your thoughts on the M for reoccurring uti S. Um Again, D Mayo's is something I don't use. I often tend to refer uh patients to GP because they are much better at using D May Os or other products. In terms of recurrent uti, I don't treat UTI S in my practice because it's usually the GP and the urologist who are the treatment experts. I often offer vaginal estrogen while urinary infections are treated. I often say if somebody is menopausal or perimenopausal, they are having UTIs while you do anything else, the demens or the antibiotics and other forms of treatments, try a bit of vaginal estrogen because for all, you know, that will reduce your chance of getting another one. It always helps in my opinion. That's my personal opinion. Great. Thank you. And Lorna is asking, does vaginal estrogen help with symptoms of mild anterior vaginal prolapse? Again, depends on what symptoms you're describing. Of course, it won't reverse the prolapse that has already happened. What it's meant to do is vaginal estrogen can help local pelvic floor muscle. So the tone of the muscle, the strength of the ligaments that are holding the tissues, the uterus and its structures and support the main aim of using vaginal estrogen in that setting is to try and tone up the muscle. So hopefully the the the the prolapse won't worsen further. If you're doing your physiotherapy along with vaginal estrogen, how much specific impact it has on symptoms such as the dragging pain or urinary symptoms that varies from person to person, but certainly it won't, uh, it won't harm you in any way. It will mainly add or, or benefit you to some extent. Brill. Ok. And Alison is asking, are there any side effects to yes or sweety? No. So, uh, sometimes the, the, the funny thing is, uh, some women complain when they use non hormonal treatments such as lubricants or moisturizers that these themselves cause irritation. Now, we've seen that previously with sort of different ph than not a ph close to four or they contain other elements, uh glycerine, for example, or other sort of uh additives which may irritate vaginal mucosa, which is why we've kind of uh a lot of uh us tend to use these specific ones because they are more close to physiology. They don't tend to irritate. So if you use any uh nonhormonal lubricant moisturizer and find that it irritates the vagina or vulva, try a different one, try a different one that usually hopefully will work for you and not irritate the skin. Thank you. Lorna's asking is GSO gel only available on private prescription. I certainly don't have it in the NHS place where I work. Um So it's, I think available in different NHS Trusts, uh patchy where it's been added to the formulary. Uh I don't know which trust have it on the formulary, but not across the NHS. So a lot of patients have to get it privately