I was fortunate enough at the North American Menopause Society Conference in Orlando last month to have a great interview with Sheryl Kingsberg, PhD, Division Chief, OB/GYN Behavioral Medicine, University Hospital Cleveland Medical Center; Professor, Obstetrics and Gynecology, and Professor, Reproductive Biology and Psychology, Case Western Reserve University School of Medicine
Madeleine Burnside: Just to explain, I do not have a medical background, I’m a historian, and what I do is interview people about their experiences and try to document those. Folks have asked me if I would interview doctors who were not GPs but more committed to the whole menopause concept.
Sheryl Kingsberg: Well, I am the Chief of a division of behavioral medicine that is within an OB/GYN department at University Hospital’s Cleveland Medical Center, so I have a very small division but get to interact with all of my physician colleagues, which makes it easier for them to make referrals to me. I’m also a Professor in two departments at Case Western Reserve University School of Medicine. And if you want the historical perspective, I started in this field twenty-five years ago, long before I was menopausal, because I thought that menopause was interesting from afar to research and to treat clinically, and now here I am.
MB What attracted you to this field, because it’s not a common thing.
SK Two things. I do behavioral medicine, particularly women’s health, and menopause was a rich area for that because psychologically we don’t really understand what the changes are that would be related to the loss of ovarian function, both neurochemically and in terms of midlife women—what are the psychological changes that are related to physical hormonal changes, and what about midlife and changing roles and ageing in general and relationships—and so the interaction as a biopsychosocial perspective was fascinating to me. Menopause was certainly near and dear to what was interesting to me. And also my other area of research is sexual function, so the impact of ageing and menopause on sex is something I’ve been studying, again, for twenty-five years.
MB Was there anyone in your family who modeled menopause at all for you, or has watching someone going through it inspired you in any way?
SK No, because I didn’t really think about the menopausal transition. Aging was certainly something I admired in my family. My grandmother was the matriarch when she died at 103, and both my mother in her 70s and my grandmother in her 90s—after long marriages where my father and grandfather had each passed away—fell in love in older age, so I absolutely knew that sexuality would remain important to women as they aged.
MB Could you tell me something about your study?
SK I have two studies. This particular study was sponsored by Newell, an amazing company working on non-hormonal non-medical devices that I think will enhance the lives of aging women beyond the point of being about just fixing a problem. Again, we assume that all sexuality for older women is going to be problem-based, but even without problems women want enhancement. This survey was about older women—older as defined by 40 to over 75—looking at about five hundred women who responded to the survey who, in order to be in the survey, actually had to have a sexual concern. We wanted to know what are their concerns—are they interested in being sexual, and were their concerns being addressed by their healthcare provider. The two most common problems were first, loss of sexual desire, which distresses people. There’s this myth that if women lose their sexual desire who cares—it’s a natural part of aging and they’re supposed to learn to live with it, and that’s not right; women want to want. And second is sexual pain, which is related to the loss of estrogen and changes in the vagina and the vulva, so we call it vulvovaginal atrophy, which is kind of pejorative to many women but is essentially accurate. Without estrogen in the vagina the tissue becomes thin and dry, and the vagina itself will narrow—it’s a use-it-or-lose-it situation because we need to keep it stretched—and the vulva loses sensitivity. We have safe and effective treatments, and yet one of the results of the survey is that women aren’t talking to their providers about it and their providers aren’t opening the door to that conversation, and so they suffer in silence with pain, and there are so many ways we can address that. Let’s say we have sixty-four million post-menopausal women, at least thirty-two million of them have vulvovaginal atrophy and only seven percent of those are on prescription therapy.
The other thing from the Newell survey is that women would like their healthcare provider to open the door. They are still having healthy, satisfying relationships with their partners, and while sexual concerns are a problem they’re not necessarily destructive to their long-term relationships, and that’s good news. The women who are the most distressed are those in their 40s as opposed to older women, and we have some theories about that. One is that peri- and recently-post-menopausal women are more distressed by the changes because they’re new to them and they are not happy about it, and also they haven’t learned how to accommodate in the ways older and more experienced, more mature women have. In older couples, if there’s a male partner with some erectile dysfunction, then they’ve sort of adapted or adjusted to his changes, or together they’ve worked out solutions because they’ve had to. And also unfortunately some of that is a bit of a complacence, a learning-to-live-with-it. Where women who are in their 40s may be a little bit more feisty about that, women in their 60s and 70s may have different or lowered expectations.
MB Can you tell me about your other study?
SK Sure. The Empower Survey was over eighteen hundred women, all of whom had to have a symptom of vulvovaginal atrophy, either dryness or pain with sexual activity. What we were looking at there was their perceptions of treatments, whether they even knew what VVA was. The fact was that the vast majority did not know that term, and they did not know the symptoms they were experiencing were directly related to menopause. We are essentially a bright and educated population, and yet there is a big disconnect to understanding about menopause and the changes that occur with the loss of estrogen. I believe there’s still a double standard in our society and we don’t talk comfortably about vaginal changes in women, and I don’t think that women are being educated enough with their healthcare providers. It’s up to the clinician to offer some education. As I mentioned earlier, seven percent of women are taking therapies, and we asked them what would stop them and many women are afraid of absorption of a local estrogen. There’s a misperception there, some of which is pushed by reading the package insert, and we have that information from the survey as well. The majority of women read the label on these products that are a local estrogen, and when it says the same warnings as systemic hormones—that it may cause dementia, breast cancer and stroke—they’re afraid to use it. That’s a big problem, and I don’t think physicians talk about it—they assume that if a patient is suffering she will bring it up, which is not necessarily the case because she doesn’t know it’s related to menopause, she doesn’t know it’s okay to talk to her doctor or nurse practitioner about it, and so again she suffers in silence.
MB I think too that people don’t see sex as part of their overall health.
SK You’re absolutely right, they are not thinking about it as a topic or area to be addressed by their healthcare professional, where that is absolutely not the case. In fact, the World Health Organization has stated very clearly that sexual health is a basic human right, and that it is up to your healthcare provider—particularly in reproductive health, so for example gynecologists for women—should be addressing this with you.
MB So why does the insert in the package say that it could cause stroke, breast cancer and dementia?
SK Because it is a label for all estrogens, it’s a class label and the class is estrogen. NAMS in particular is supporting a citizen’s petition that has gone to the FDA, and there is a congressional letter that’s going out from women in Congress supporting this change to the packet insert with the FDA, so that we can have better safe and effective treatments. In the long run it’s a cost savings to the healthcare system because women wouldn’t be suffering with chronic UTIs or bladder problems.
About two years ago the International Society for the Study of Women’s Health and NAMS had a consensus conference to try to come up with a better term than VVA, because it’s limited to the area and, again, it’s pejorative. And so genitourinary syndrome of menopause was what we came up with because it covers the fact that the tissue involved is also in the bladder and other urogenital areas, and if you don’t treat the urogenital area you’re going to have a lot of medical problems beyond the most bothersome symptoms of pain or dryness. Women will say I can’t exercise, I can’t wear tight clothing—this is a pervasive problem.
MB And so does an estrogen cream affect that at all, does it affect the whole urogenital system?
SK Does it help—absolutely yes. If you can get to inserting in the vagina it can also reach the urogenital tissue to allow for restoration of that tissue, because there are different kinds of cells in the vagina versus the urogenital tract but they’re both relevant to estrogen supply, so it will help in all areas. And again, dysuria and frequency for example– those urinary issues will be improved as well.
MB Well, that’s certainly worth knowing, because that affects many people too.
What else should I be asking you?
SK The Newell Survey sends a message that women want to remain sexual long into their older age and have healthy sexual lives, and that sex isn’t just for the young. The Empower Survey, which focuses specifically on GSM, reflects the fact that women are not being educated about menopause and some of its key symptoms; and again, there’s a disconnect with that conversation with their healthcare provider. I’m giving a talk tomorrow on hypoactive sexual desire disorder, which is the persistent loss of sexual interest and a problem in women of all ages, with the highest prevalence being probably in that 45 to 65 range. It is not about pain or dryness or VVAs—this is the persistent loss of interest in sexual motivation, responsive desire, spontaneous desire, that is not due to a medical or psychiatric condition or medication or a bad relationship—those are all the rule-outs.
MB So what is it due to?
SK Well, we consider desire as a biopsychosocial construct. There are psychological factors and sociocultural factors that either increase or inhibit our desire, and there are also biologic factors, neuro and anatomic. We know that the locus of desire is in the brain. The prefrontal cortex is important for reward processing and neurotransmitters such as dopamine or norepinephrine or melanocortins are all responsible for reward processing and excitation, whereas other neurotransmitters and neurochemistry like serotonin work to inhibit sexual desire; anybody who’s ever been on an SSRI probably knows that one of the major side effects is loss of sexual desire, and the increase in serotonin is responsible for that. It works nicely for anxiety and mood but it is not good for sexual desire. So think about desire as sort of a tipping point or a scale – on one hand you have things that increase excitation which improves desire, that would be on the biologic side and on the psychological or interpersonal side, you’ve got all those good neurotransmitters working towards excitation or romance or intimacy. On the inhibition side you’ve got serotonin, endocannabinoids, and also on the psychological side a bad relationship or stress or negative beliefs about sex or bad experiences with sex. So it’s really a balance.