REPRODUCTIVE HEALTH & MENOPAUSE

Reproductive Health and Menopause

A 2018 survey of more than 7,500 women by Public Health England⁽¹⁾ found that for three quarters of women, what they had learnt at school was the extent of their knowledge with regards to their reproductive system and health. Worryingly this knowledge was often described as basic and insufficient to allow them to manage their reproductive health needs throughout their lives.

It has been demonstrated that negative reproductive symptoms can have a significant detrimental effect on the wellbeing of women. Eighty percent of women in the survey reported having experienced unwanted reproductive symptoms including issues related to menopause and heavy periods but only half of women sought medical help due to embarrassment, fear of judgement and stigma. Knowledge of reproductive health is important in breaking down these barriers and empowering women to make informed choices with regards to their health as well as enabling them to manage unwanted symptoms.

Women’s reproductive needs vary widely between individuals and according to different stages of life. However they can generally be grouped into the following areas:

Period problems

Heavy and/or painful periods is one of the commonest complaints we see in Gynaecology. It’s a very subjective complaint but in general, excessive blood loss is accepted as being that which interferes with the woman’s quality of life. Signs that suggest that bleeding is excessive include flooding through clothes and bedding, the passage of large clots and needing to use double protection or change sanitary wear very often. The majority of women won’t have any underlying disease process causing this but there are important conditions to rule out such as infection, endometriosis (a condition where the lining of the womb grows elsewhere) and fibroids (benign growths of the uterine muscle). Fibroids in particular are more common amongst black women for reasons we don’t yet understand but are thought to share genetics with keloid scarring which is also more prevalent among the black community. In addition to causing menstrual dysfunction, depending on size and location they can on occasion interfere with conception and pregnancy.

Fertility & contraception

For most women, either achieving or preventing pregnancy is a major concern throughout most of their reproductive lives. Miscarriage and infertility are not often talked about despite the fact that they will impact 1 in 4 women and 1 in 7 couples respectively. As a result many women harbour the belief that conceiving is easily achievable and are consequently unprepared to handle any difficulties should they arise.

Good contraception is essential in preventing unwanted pregnancy but unfounded beliefs regarding contraception (both regular and emergency) are widespread. Common myths include the assumptions that you can’t get pregnant the first time you have sex or if you have sex during your period, and beliefs concerning the impact that hormonal contraceptives have on weight and future fertility. Reputable information regarding contraception can be found on the NHS website.

Pregnancy

The most recent reports from MBRRACE-UK⁽²⁾ (the collaboration that records and investigates the causes of maternal deaths, stillbirths & infant deaths nationally) reveal that black women are 5 times more likely to die during pregnancy & the postnatal period than white women, those of mixed ethnicity are three times as likely and Asian women twice as likely. Maternal deaths are categorised as either direct (directly related to pregnancy), indirect (usually due to a pre-existing medical condition) or coincidental (completely unrelated to the pregnancy). The data we have from the MMBRACE reports shows that 3 times as many Black African women died due to indirect causes as opposed to direct causes. This is in contrast to Black Caribbean women and Asian women for whom the rates of direct and indirect causes were similar. Other important findings from the report include the fact that out of all the women who died, 2 out of 3 had pre-existing medical conditions, 28% had pre-existing mental health problems, more than half were classified as overweight or obese and two thirds did not attend all of their antenatal appointments. While we don’t currently fully understand the reasons behind the increased mortality in black women and it is likely to be multifactorial, this finding does highlight the important role that pre-conceptual counselling, optimisation of pre-existing medical conditions and maintenance of a healthy body mass index (BMI) can play in ensuring a safe, successful pregnancy. Heart disease was the number one killer of pregnant women and unfortunately this may only present for the first time during pregnancy for some women. In view of this, it is vital that women understand the red flag symptoms they should look out for including:

• Severe chest pain, particularly if it radiates into the jaw or down the arm
• Fainting during exercise
• Breathlessness at rest and especially breathlessness while lying down

Among the key messages for women, the report also highlighted the importance of attendance at antenatal appointments in order to monitor existing conditions and detect developing problems and speaking up if you have concerns about your pregnancy.

National data on infant mortality shows that while overall infant mortality rates have improved for most ethnic groups, they have worsened among Indian and Bangladeshi women⁽³⁾. In addition, infant mortality continues to be highest among those of Pakistani origin, followed by Black African and Black Caribbean ethnicities⁽³⁾. Prematurity related conditions were the most common contributor to infant mortality apart from babies born to Pakistani or Bangladeshi mothers where congenital abnormalities were the most common cause of death. While it can be difficult to predict and/or prevent prematurity, ensuring that pregnant women take the appropriate dose of folic acid from as early as 3 months prior to conception can recue the risk of congenital anomalies.

Screening

A number of studies have identified people from BAME backgrounds as being at higher risk of acquiring sexually transmitted infections (STIs)⁽⁴⁾. A study looking specifically at young people in London found that not only were black people far more likely to engage in sexual intercourse earlier, but also that non-use of contraception during first and subsequent sexual encounters was most commonly reported amongst Black males, Black African females and Asian females⁽⁵⁾. In addition to the immediate negative impact, STIs can have unintended long term consequences particularly when it comes to fertility. In view of this it’s important that women are equipped with the knowledge of how to protect themselves (ie contraception) and how and where to seek help if necessary. It is recommended that all sexually active individuals are screened for STIs, particularly if starting a relationship with  new partner, having sexual relationships with more than one partner or a partner who is known to have an STI.

The National Screening Program for Cervical Cancer was established in the UK in the 1980s. The 4^th most common cancer in women worldwide, cervical cancer usually develops between the ages of 25-45 with 99% of cases being caused by the Human Papilloma Virus (HPV). While the rates of cervical cancer are lower in the UK, it still remains a significant health problem despite being easily preventable. Screening prevents up to 75% of cancers from developing and those who have been screened have an 80% lower risk of being diagnosed with cancer in the subsequent 5 years. Despite rates of cervical cancer being comparable between black and white women ⁽⁶⁾, black women are more likely to die from it⁽⁷⁾. This may be due to a number of factors including the fact that black women are less likely to attend screening⁽⁸⁾ meaning that their cancers are detected later and are therefore more difficult to treat. In addition, research from the USA has shown that not only does the cervical cancer vaccine not cover the most common types of HPV in African American women⁽⁹⁾, but also that high risk HPV infections persist much longer in African-American women than their white counterparts⁽¹⁰⁾.

Menopause and beyond

The average age of menopause in the UK is 51. Approximately 80% of women will experience symptoms and for around a quarter of these women these symptoms will be severe. Although menstruation has stopped, the reproductive system can still play an important part in heath & well-being and in addition to the unwanted symptoms associated with menopause, it is at the stage that we commonly see issues such as prolapse and incontinence (involuntary leakage of urine). It is important for women to be aware of the continued need for contraception for up to 2 years after menopause (depending on the age at which menopause occurred) as well as the need for continued cervical screening up until age 65. Being aware of what should be normal at this stage of life is essential in helping women identify worrying symptoms such as postmenopausal bleeding (which in a small proportion of cases can be a sign of cancer) enabling them to seek help in a timely fashion.

Where to find more support

RCOG Patient Information Leaflets

https://www.rcog.org.uk/en/patients/patient-leaflets/

NHS Information on contraception

https://www.nhs.uk/conditions/contraception/

References: 

1. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/731891/What_do_women_say_reproductive_health_is_a_public_health_issue.pdf
2. https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202019%20-%20WEB%20VERSION.pdf
3. gov.uk. 2020. Child And Infant Mortality In England And Wales – Office For National Statistics. [online] Available at: <https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2018#inequalities> [Accessed 14 July 2020].
4. Tripp, J. and Viner, R., 2005. Sexual Health, Contraception, And Teenage Pregnancy. [online] The BMJ. Available at: <https://www.bmj.com/content/330/7491/590.long> [Accessed 14 July 2020].
5. https://lemosandcrane.co.uk/resources/Naz%20Project%20London%20-%20Sexual%20health%20knowledge,%20attitudes%20and%20behaviours%20among%20black%20and%20minority%20ethnic%20youth%20in%20London.pdf
6. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer/incidence#heading-Six
7. https://www.cancer.net/cancer-types/cervical-cancer/statistics
8. Ekechi, C., Olaitan, A., Ellis, R., Koris, J., Amajuoyi, A. and Marlow, L., 2014. Knowledge of cervical cancer and attendance at cervical cancer screening: a survey of Black women in London. BMC Public Health, 14(1).

https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-14-1096

9. Cathrine Hoyo, S., 2014. HPV Genotypes and Cervical Intraepithelial Neoplasiain a Multiethnic Cohort in the Southeastern United States. Journal of Vaccines & Vaccination, 05(03).

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4082644/

Banister, C., Messersmith, A., Cai, B., Spiryda, L., Glover, S., Pirisi, L. and Creek, K., 2014. Disparity in the Persistence of High-Risk Human Papillomavirus Genotypes Between African American and European American Women of College Age. Journal of Infectious Diseases, 211(1), pp.100-108.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4326315