FGM and the perimenopause and menopause

• Little research exists on menopause experiences of women living with FGM
• Women affected by FGM share the impact of menopause
• This guide offers advice on symptoms, treatments, lifestyle changes and sources of support

Every woman living with FGM will become menopausal.

If you’re under the age of 50 years, even if it feels like this will be some years away, if you have experienced FGM, it’s important to be prepared for perimenopause and menopause and know how you might be affected.

But what is menopause, and how can FGM impact your menopause?

This guide has been written healthcare professionals (menopause specialists, general practitioners and gynaecologists), and includes valued contributions from women living with FGM, and from FGM advocate and survivor Sarian Kamara from charity Keep the Drums, Lose the Knife.

More than 200 million girls and women have undergone female genital mutilation (FGM).

A deeply rooted cultural custom involving the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons, FGM is recognised as a human rights violation [1]. Complications can include severe bleeding and problems urinating, cysts, infections, complications in childbirth and lasting psychological trauma.

If you are living with FGM and are unsure of what to expect, you aren’t alone: Sarian Kamara says many women affected by FGM don’t know the signs and symptoms of menopause, and that more information is desperately needed.

‘They first notice it affecting their relationship with their partner, their children and their wider family,’ she says.

‘Some women tell me they all of a sudden feel anger at small things, and it affects their relationship with their children. ‘Many women don’t go to their GP, not because of fear, but because they don’t know what menopause is, they don’t know that the problems they’re experiencing, hot flushes, sleep problems, weight gain, mental health issues, are actually due to menopause.’

Researchers at Newson Health are working with FGM advocates and survivors to understand the impact of menopause on women living with FGM. For an in-depth look at the health needs of women living with FGM going through the menopause, you can access the paper for free here.

Over the last two years, Newson Health and Keep the Drums Lose the Knife have arranged several menopause workshops for women living with FGM.

Among those who attended was Amina, a 52-year-old woman from Somalia.

She says of her menopause symptoms: The hot flushes and night sweats are really hard, but the pain from my scars made it even worse.

‘It felt like my body was punishing me all over again.’

What is perimenopause and menopause?

Menopause is when your ovaries stop producing eggs and levels of hormones oestrogen, progesterone and testosterone fall. Once the hormones are low then they stay low forever, so menopause essentially lasts forever (although the impact of low hormones can be corrected, as this guide explains).

The definition of menopause is when a woman hasn’t had a period for 12 months, and the average age of the menopause in the UK is 51. However, it doesn’t just happen in mid-life, all women are different and they can experience menopause at very different ages. Menopause before 45 is known as an early menopause, while menopause before the age of 40 is known as premature ovarian insufficiency (POI). POI occurs in around one in 30 women under 40 so is actually very common.

Perimenopause

Perimenopause is the time before established menopause, when you are still having periods, but the fluctuating and low hormone levels can cause numerous symptoms, including hot flushes, brain fog and mood changes. Periods may occur further apart or closer together; they can be more irregular, or heavier or lighter in flow. The perimenopause can last for several years, and the length of this period varies from woman to woman.

The role of oestrogen, progesterone and testosterone – and symptoms you may experience

These three hormones have important functions in every cell of your body. Throughout your body, cells have hormone receptors waiting to receive instructions from these hormones to tell them how to work properly. During your perimenopause, levels of oestrogen, progesterone and testosterone fluctuate and reduce. These changes can lead to a wide variety of symptoms including:

• If you already suffer from premenstrual syndrome (PMS), you may find symptoms before your period become more severe during perimenopause
• Mood swings, low mood and/or anxiety
• Memory problems
• Hot flushes and night sweats
• Joint aches and pains
• Brain fog
• Sleep disturbance
• Headaches and worsening migraines
• Dry and itchy skin

Menopause and your vagina, vulva and surrounding tissues

Oestrogen, progesterone and testosterone keep your vagina, vulva and surrounding tissues healthy. They act as a natural lubricant, maintain vaginal and vulval tissue and give flexibility to the wall of your vagina. They also stimulate the cells in the lining of your vagina to encourage the presence of ‘good’ bacteria that protect against infections and keep the lining of your urethra and bladder healthy, helping to reduce bladder and urinary tract infections.

Hormone changes during perimenopause and menopause can trigger a range of symptoms affecting your vagina, vulva and urinary function, known as genitourinary syndrome of menopause (GSM).

The tissues lining your vagina can become thin, inflamed, drier and less able to stretch. Scar tissue may become more painful and tears in and around your perineum may occur. This often makes the area feel sore and itchy (you may also find your skin feels itchy in other areas too). Scratching usually leads to more soreness and inflammation – often making the problem worse.

Your urethra (opening where urine flows) and bladder can also become thinner and weaker, leading you to pass urine more often and feel very desperate to go. You may also experience some urine leaks or accidents – especially when you cough, sneeze, laugh or during exercise – and you may also experience more frequent episodes of thrush or cystitis.

Pain is another common symptom. This can impact everyday activities, including how long you can sit down for, and the type of clothing you wear. You may feel discomfort or pain when the tissues are stretched, such as during sex or during cervical screening.

Replacing the low or missing hormones can help to improve these symptoms. Vaginal and urinary symptoms can occur before other symptoms of perimenopause or menopause start so it is important to be aware that they could be related to low hormones and not due to worsening of the scars from being cut in the past. The sooner you receive treatment, the better you will feel and the less likely you will suffer.

Menopause experiences of women living with FGM

‘I don’t know what is going on…one day my mood is fine and the next I’m screaming at everyone for everything. I have a lot of pain and dryness down below.’

Kadiatou (49) from Guinea

‘I struggle with urinary problems and it hurts a lot down there. I don’t know how to talk to my doctor about it. No one understands my pain.’

Zahra (51) from Sudan

‘I haven’t had many problems with intercourse before, it now it’s getting worse. I don’t understand the menopause or what treatments are there or how to even access them. We, as a community, need more support with this.’

Mariama (52) from Sierra Leone

How FGM can affect my perimenopause and menopause?

An earlier menopause: Complications from FGM, such as pelvic infections or surgery, may mean you will experience menopause at a younger age.

More susceptible to GSM symptoms, such as vaginal dryness: FGM can cause scarring and the tissues in your vagina to become stretched or thin. Early treatment with vaginal hormones could help to improve this. Vaginal hormones can be prescribed as creams, pessaries or a soft ring that sit in your vagina. The hormones will thicken your tissues, reduce pain and also encourage blood flow and healing to these areas.

Your periods might worsen during perimenopause: You may already have painful or heavy periods because of your FGM, and changing hormone levels during perimenopause can lead to heavier periods.

A bulge or sensation of dragging might be a symptom of a prolapse: Some types of FGM can increase the risk of developing a vaginal prolapse, particularly if FGM was performed at a young age [2]. During perimenopause and menopause a decline in hormones can also increase the risk of prolapse. A combination of pelvic floor exercises with use of vaginal hormones can help to improve this.

Menopause might be a time when you need to take extra care of your mental health: It is well-known that FGM can cause lifelong anxiety, depression and PTSD [3]. Perimenopause and menopause can trigger or worsen these conditions, and this is often due to fluctuating or low hormone levels in your brain.

Experiencing new symptoms? They could be hormone-related If you have symptoms that are changing it is important to consider reducing or low hormones and not assume it is as a result of FGM. Many symptoms caused by low hormones overlap with symptoms from FGM including vaginal pain, discomfort or altered sensation, urinary problems and uncomfortable sex. It’s important to speak to a healthcare professional to discuss further.

Caring for yourself

It’s important to care about yourself, and to find ways to get help. This might mean speaking to your GP, or reaching out to friends or family. Let them know what is bothering you. Try to find a way to ensure your partner is aware that you’re having symptoms that might impact your relationship. Be caring towards yourself, but don’t suffer in silence.

Try to keep a broad approach as there is no single ‘right’ way to improve perimenopause and menopause, just bear in mind that they can affect your physical and mental health and how you feel will often vary from day to day.

Rest well: you may be managing along hours at work and/or caring responsibilities, however getting a good night’s sleep is crucial. Try to aim for seven to eight hours every night by having a consistent routine of going to bed at the same time every night and getting up at the same time too.

Stay active: exercise is important for your general health, and it helps keep your bones and heart strong too. This doesn’t mean you have to spend lots of money on an expensive gym membership, or spend hours a week at classes: it could be walking more, or doing free workouts at home. If fatigue is a factor, start with a lower impact activity that is slow and gentle, and gradually build up the duration and frequency you are active for.

Make time for you: spending time doing things you enjoy helps you feel better. Whether that is going for a long walk, or spending some much-needed time with loved ones. Learn to value time just for you.

Eat well – foods that are important are those rich in calcium and vitamin D for your bones, friendly to the gut like pre- and probiotics, carbohydrates that have a low glycaemic index (GI) and are broken down more slowly, and foods rich in omega 3 oils.

Hormone replacement therapy (HRT)

HRT is the most effective treatment for perimenopausal and menopausal symptoms as it replaces the missing hormones, and for most women, the benefits of taking HRT outweigh any risks.

HRT is a term for the different hormonal treatments you can take for perimenopause and menopause. It usually contains the hormone oestrogen – the key hormone that affects so many different parts of your body when you don’t have enough of it.

If you take replacement oestrogen, you need to take another hormone to protect the lining of your womb (if you still have one) and this is known as progesterone or progestogen.

There is a third hormone, testosterone, that you naturally produce when you are younger, that can also be used as part of HRT.

How to take HRT

Oestrogen: the safest way to take oestrogen is through your skin, via a sticky patch, gel or spray. There is also a tablet form. You will need to take it every day, and the dose often varies depending on how you absorb the oestrogen through your skin.

Progesterone: this is usually just for women who have their womb to protect the lining of your womb from the effects of oestrogen but it can also be taken by women who have had a hysterectomy.

The preferable type is micronised progesterone and it comes in a capsule form that is taken daily, often in the evening, as it can also have a mildly sedative effect. The capsule is usually swallowed but it can also be inserted vaginally. An alternative type of progesterone is via a Mirena coil, a small plastic device inserted in your womb that stays there for five years and is then replaced.

Testosterone: this comes in a cream or gel that you rub into your skin every day. Testosterone can help to increase libido and many women find that it can also improve symptoms of low energy, mood changes, poor sleep, fatigue and poor concentration.

These three forms of HRT are called systemic HRT, meaning they are absorbed into your bloodstream and make their way around your whole body.

Benefits of systemic HRT

Your symptoms will improve: usually within three to six months of starting HRT.

Your risk of developing osteoporosis reduces: your bones will be protected from weakening due to lack of oestrogen.

Your risk of cardiovascular disease reduces: you will be less likely to develop heart problems, stroke or vascular dementia.

Your risk of other disease reduces – those who take HRT also have a lower future risk of type 2 diabetes, osteoarthritis, bowel cancer, clinical depression and dementia.

Risks of systemic HRT

Deciding to take HRT should be the result of an individualised conversation with your healthcare professional based on your medical history and personal preferences. You can find out more about risks and benefits of HRT here.

What about side effects?

Side effects with HRT are uncommon but can include breast tenderness, leg cramps or some vaginal bleeding. If side effects do occur, they usually happen within the first few months of taking HRT and usually settle as your body adjusts to taking the hormones.

Vaginal hormones

Women living with FGM often have scar tissue or skin changes that can change during the menopause. As tissues become less lax and often less lubricated, new pains can occur. Vaginal hormones (also known as local or topic hormones) can help with symptoms affecting your vulva, vagina and surrounding tissues, including alleviating painful sex and preventing infections.

Vaginal hormone treatments can be taken safely for a long time, with no associated risks, and can be given with or without HRT. The majority of local hormone treatments are currently only available via prescription – your healthcare professional should be able to advise on which type would be best for you.

Different types of vaginal hormones

Pessary: this is inserted into your vagina, often using an applicator. Pessaries contain either oestrogen or a hormone called DHEA, that your body naturally produces. Once in your vagina, DHEA is converted to oestrogen and testosterone.

Cream or gel: these can be useful if you are experiencing itching or soreness of the external genitalia.

Ring: a soft, flexible, silicon ring you insert inside your vagina, which releases a slow and steady dose of oestrogen over 90 days. Needs replacing every three months. A health professional can insert the ring if you do not feel confident or able to do so. You can leave the ring in position to have sex, or remove and reinsert it, if preferred.

Symptoms of GSM will not resolve on their own, so vaginal hormones are safe to use long term. Women who cannot have HRT for clinical reasons can still use local hormone treatments in the vagina.

Non-hormonal treatments

Whether you take HRT or not, it is worth considering lifestyle options or treatments to optimise your symptoms. There are many things that may improve your symptoms, including taking non-hormonal medications, talking and alternative therapies.

Vaginal moisturisers and lubricants

Vaginal moisturisers and lubricants do not contain hormones but can work to keep the tissues well-hydrated and feeling less sore. Moisturisers help throughout the day and are longer lasting, so you may only need to use a moisturiser every two or three days. Lubricants are for using just before sex or any other activity that penetrates your vagina.

Both moisturisers and lubricants can be used alongside vaginal hormone treatments.

Prescription medicines

Some prescription medicines could help to relieve your perimenopausal and menopausal symptoms. Certain types of antidepressants, the high blood pressure medication clonidine, and the epilepsy medication gabapentin, may help with symptoms like hot flushes, night sweats, low mood, anxiety and vaginal dryness. Although these can work for some women, they might not be suitable for you, and they can have some side effects.

Cognitive behavioural therapy (CBT)

CBT is a talking therapy which has been shown to help reduce some mental health symptoms, including depression and anxiety. It works by helping you to identify your thoughts and feelings and teaches you coping skills so that you’re more able to deal with them.

Herbal medicines

Herbal medicines like St John’s wort, black cohosh and isoflavones like red clover, which are available to buy over the counter in chemists and health food shops. Although some claim to ease menopausal symptoms it’s important to remember that just because a product is natural, that doesn’t necessarily mean it’s safe. Scientific evidence is mixed on how effective these treatments are, and they can have side effects or interfere with other medicines you might be taking.

Alternative therapies

You might find that massage, acupuncture or aromatherapy help to relieve your menopausal symptoms. There’s little scientific evidence to support their use, but these therapies are likely to help you relax so could be worth a try.

Sources of support

Keep the Drums Lose the Knife

Womankind worldwide: list of FGM support organisations

References

1. World Health Organization (2022), ‘Female Genital Mutilation’, https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation
2. Birge, Özer et al. (2021), ‘Female genital mutilation/cutting in Sudan and subsequent pelvic floor dysfunction’, BMC Women’s Health, 21(1), doi:10.1186/s12905-021-01576-y
3. Reisel, D.,  Creighton, S. (2015), ‘Long term health consequences of Female Genital Mutilation (FGM)’, Maturitas, 80(1), pp.48-51, doi:10.1016/j.maturitas.2014.10.009