October 2023
This month we talk with Shelly Coe, MD and certified NAMS (North American Menopause Society) about the changes that occur during menopause. She explains the effect of declining estrogen on the genital and urinary systems, and shares her recommendations for lifestyle changes and treatment options to support vaginal and hormone health.
Shelly R. Coe, MD, MSc, NCMP, is a UCLA-trained gynecologist and a certified menopause practitioner in Newport Beach, California. Dr. Coe takes an evidence-based approach to care, focusing on her patients’ physical and social wellbeing. She’s passionate about building trust, and partners with patients on their journey to meet their health and wellness goals. She provides expert care to women of all ages, including teens.
SHWI: What led you to your career in Obstetrics and Gynecology and what inspired you to become a certified Menopause Practitioner?
As far back as I can remember, I had big dreams. To be a veterinarian, race car driver, jockey, gymnast, dancer…I loved learning and challenging myself physically. I left home after graduating high school at 17 to pursue my dream of a college education. I was a first-generation college student working full time to pay for college and support myself. I actually started college as an art major, though I was always fascinated with science, anatomy and the inner workings of humans and animals. I distinctly remember taking a life drawing class at the same time as a human anatomy course which sparked a new dream to become a physician.
This was also fueled by my athletic pursuits and interest in nutrition and health. I was persistent and able to start medical school 10 years later. I initially thought I would be interested in pediatrics, but as I completed my rotations through all medical specialties in my third and fourth year of medical school—it was very clear I loved the surgical specialties. I had worked for a family planning center in my early 20s and in the back office for an Ob-Gyn the year before I applied for medical school.
This exposure and familiarity with women’s health along with my experience on rotations with the UCLA Ob-Gyn department solidified my decision to complete an Ob-Gyn residency. I learned to appreciate women over those four years! I initially had a private Ob-Gyn practice, then took time off for family and to raise my children. During this time, I went through the menopause transition and other midlife challenges (do not forget aging!). Before I returned to private practice, I become a North American Menopause Practitioner to improve my ability to collaborate with women to take charge of factors that influence their health, meet their healthcare goals, and live empowered lives. I love my work!
SHWI: How does the vaginal biome change during menopause and how does that affect vaginal health and sexual function?
Decreasing estrogen levels during the perimenopause transition and lack of estrogen postmenopausal affect the health of the genital and urinary systems. Genital Urinary Syndrome of menopause (GSM) is a relatively new medical term that encompasses these signs and symptoms due to the effect of estrogen deficiency in the vulvar, vaginal, urethral and bladder areas. Estrogen deficiency causes thinning of the vaginal epithelium, decreased blood supply, loss of moisture and a change in the pH from acidic to basic. This causes the microbiome of the vagina to be fragile, and yeast or bacteria can more easily overgrow.
Common symptoms of GSM include:
- Vulvar or Vaginal dryness, irritation, or burning
- Decreased vaginal lubrication with sexual activity
- Discomfort or pain or bleeding with sexual activity (dyspareunia)
- Decreased arousal and/or desire
- Burning during urination
- Frequent urinary tract infections
- Urinary urgency and frequency
SHWI: What are some treatments that can support women as they transition into the perimenopause and menopause stages of life?
I encourage all patients to make lifestyle changes that can support general health through this transition such as maintaining a sleep schedule, exercising five days per week, decreased alcohol intake and calorie restriction to maintain ideal adult weight for height. I encourage vitamin D and a calcium rich diet to prevent osteoporosis. It is important that women understand the top three causes of cancer in the U.S. are alcohol, obesity, and cigarettes.
Brief medical therapy for women in the perimenopause transition may include low dose oral contraceptives or a progesterone IUD along with estradiol hormone replacement therapy or cyclic estradiol/progesterone hormone replacement therapy.
Postmenopausal women may consider estradiol replacement therapy If they do not have a uterus, and estradiol/progesterone therapy if they have a uterus.
Other options include psychological support, pelvic floor physical therapy, medical therapy for hypoactive sexual desire, neuromodulators for depression/anxiety/agitation/vasomotor symptoms, and insomnia medications.
For GSM, I believe all postmenopausal and symptomatic perimenopausal women should be on lifelong vaginal estradiol therapy, use lubricants for sexual activity and a pH balanced vaginal moisturizer two times a week at bedtime. Options for estradiol therapy include
- Vaginal estradiol in the form of cream, tablets, inserts or a ring.
- DHEA vaginal inserts (prasterone) are transformed in the vagina to estrogens and androgens
- Oral estrogen receptor modulator-Ospemifene (more side effects than local therapy)
SHWI: October is Menopause Awareness Month. What should women know more about when it comes to understanding menopause? Likewise, what do you wish healthcare practitioners knew about menopause and discussed more openly with their patients?
The menopausal transition refers to changes that occur during the natural progression from the reproductive years to the postmenopausal years. Despite this being a normal physiological event, the stresses of midlife along with aging and menopause can be challenging.
Menopause marks the end of fertility, meaning there are not any eggs left in your ovary to ovulate and produce estrogen and progesterone. Women officially reach menopause when 12 consecutive months have passed without a menstrual cycle, which for most women occurs around age 52. Menopausal symptoms of estrogen deficiency actually begin before you officially reach menopause due to fluctuating hormone levels and can start an average of three years before the final menstrual period (this is the perimenopausal transition).
Common symptoms of the perimenopause transition and postmenopause include menstrual irregularities, hot flashes, night sweats, insomnia, mood and cognitive changes, joint and muscle aches, weight gain, dry skin, sexual dysfunction and urogenital symptoms. Most of these symptoms resolve or stabilize within the 10 years from the transition, except for progressive changes in the urogenital system due to lack of estrogen and loss of bone causing osteoporosis. It is critical to monitor vaginal health and bone health for the rest of a women’s life. Women need to know there are available options to relieve these symptoms even if only needed during the perimenopause transition.
I would like physicians and other healthcare providers to understand the changes that occur in the menopause transition with associated health risks and feel comfortable initiating conversations regarding sexual health and GSM. I hope that they will learn to promote evidence based options to decrease current and future health risks including FDA approved forms of hormone replacement therapy or recognize their clinical or practice limitations and have an appropriate referral.
SHWI: As a long-practicing Ob/Gyn, what advancements in research and medicine would you like to see towards improvement in gynecological health?
I am so thankful we have become a globally connected society and hope that we can decrease media misinformation, put risks into perspective and improve access to evidence based information to allow informed choice and empower women to maintain health throughout their lifetime.
I hope that health care providers are required to learn about sexual health, menopause, and understand the risks and benefits of all hormone therapy, including contraceptives. Further education and research is necessary to clarify risks and benefits of the different forms of hormone replacement therapy so that policy is more favorable towards postmenopausal women and therapy options.
I hope for a future that provides basic preventive healthcare coverage to all women. A future where hormone replacement therapy is covered by health insurance, and contraception and vaginal estradiol therapy are offered over the counter at your pharmacy.
Resource:
https://www.menopause.org/docs/default-source/default-document-library/2020-gsm-ps.pdf