Tales from “the Deli” to the “Clinic”! Managing menopausal women who have spinal injuries

Menopause discussions are everywhere. I recently popped into my local deli to collect my Easter shopping order and was delighted to witness a discussion between a customer and Jane, a member of staff, about symptoms of menopause and treatment options. When I got to the till, I mentioned how pleased I was to hear their open discussion; how times have moved forward! Brian, ‘the boss’ then added that he wanted to do his best to support his workforce (who, I might add, are mostly women of a certain age! ). So, the staff are happy and healthy, and the deli continues to serve the local community efficiently. Jane went on to say how marvellous she felt on her HRT tablets, but quickly asked if I thought she was doing the right thing or whether it might cause her harm longer term. For otherwise healthy women below the age of 60, HRT is associated with more potential benefits than risks. As we age, the picture becomes more complicated in association with concomitant medical problems such as hypertension, obesity, venous thromboembolism (VTE), diabetes and hormone dependent cancers; specifically breast and endometrial cancer. Women should have ongoing assessment and support, and this is best provided by their NHS GP. The menopause is not a deficiency state like hypothyroidism, but rather a life stage which can be managed in many ways, tailored to the individual woman. Whilst hormone replacement therapy (HRT) is often associated with the best outcome in relation to symptom control and is likely to have a beneficial effect on bone health and cardiovascular risk, it is not for all women and an individualised assessment will inform and support patient choice. This seems like an ideal opportunity to review the potential benefits and risks of HRT in relation to a more challenging case of a tetraplegic patient who presented for help to manage her menopausal symptoms a few months ago. Tracey, age 52, presented with her husband, who is also her carer, asking for advice to help manage her menopausal symptoms, which included low mood and bladder pain. It was obvious that they had a very good relationship, and the consultation included a discussion on sex and sexual pleasure/satisfaction. In 1995, at the age of 25, Tracey had a spinal cord injury (SCI) as a result of a cycling accident with a C6/7 dislocation, resulting in C8 tetraplegia. This type of spinal injury is associated with a risk of autonomic dysreflexia, potentially caused by an irritating stimulus below the level of the spinal cord dissection. Nerve impulses generated in specific circumstances are unable to reach the brain, due to the injury and can set off a reflex, increasing sympathetic activity in the autonomic nervous system. This can cause narrowing of blood vessels and hypertension with affected patients experiencing headache, bradycardia, sweating above the level of the injury, goosebumps, nasal congestion and blotchiness of the skin. Before the accident Tracey was exceptionally fit and afterwards, she became mobile again using a self-propelling manual wheelchair. Her quality of life was good for many years, but in her mid-thirties she developed heavy menstrual bleeding, with periods lasting 5 days with bleeding again mid cycle, and the problem exacerbated by a short cycle, 21–23 days. A Mirena® was inserted and the problem resolved. Tracey had an early menopause, becoming symptomatic around age 44, and her last menstrual period was in December 2020. During the menopause transition, she did not experience vasomotor symptoms, due to hypothermia associated with her tetraplegia. Her main symptoms at presentation included difficulty sleeping in addition to low mood and bladder problems. Tracey was diagnosed with overactive bladder in 2014 following a urodynamic assessment. Prior to this, she managed to be continent by using intermittent catheterisation. Her husband catheterises her every 4 h, including during the night and avoidance of further disruption to sleep is important to both. She is also