Menopause
Little has been published on women’s experience of menopause post-SCI; in addition, many menopausal complications, like sweating (e.g., ‘hot flashes’) or increased frequency of bladder infections, are also common in people with SCI, which compromises the ability to correctly diagnose and treat. In their observational study, Dannels and Charlifue (2004)report presence of typical peri-menopausal symptoms in women with SCI, but at a lower rate compared to the general population. The authors hypothesize that symptoms could be mimicking those related to SCI, or that there is a lack of communication about perimenopause between providers and women with SCI (Dannels & Charlifue 2004). Jackson and Wadley (1999) also found a lower frequency of menopausal symptoms post-injury. Jackson and Wadley (1999) found that although menopausal symptoms occur at a lower frequency post-injury, women that experienced menopause pre-injury experienced even less symptoms. Conversely, Kalpakjian et al. (2010) reported that women with SCI transitioning through menopause experienced greater somatic symptoms, bladder infections, and diminished sexual arousal compared to women without SCI.
Numerous clinical questions remain unanswered; particularly a lack of information and support for the gynecological health needs of women with SCI (Pentland et al. 2002). Given that obtaining access to gynecological and obstetric care is also a challenge for many women with SCI, it raises the question of whether women with SCI are receiving adequate sexual and reproductive health care (Nosek et al. 1996; Jackson & Wadley 1999).
Discussion
There are very few studies (18 in total) that collected original data studying both women and menopause and women with SCI. Multiple narrative reviews and one qualitative study surmise that women with SCI experience menopause similarly to women without SCI (Briggs et al. 2022; Vandenakker & Glass, 2021; Chiodo et al. 2007; Pentland et al. 2002). One large survey study (Jackson & Wadley, 1999; n=472) reported that the average age of women who went through menopause before SCI 45.5 years (range= 29-55 years), and women with SCI who went through menopause post-SCI did so at an average age of 43.3 years (range=23-61 years, n.s.). Common symptoms in women with SCI undergoing menopause are menstrual cycle changes (60%), sleep disturbance (43%), night sweats (30-40%), hot flashes (39-69%), depressive, anxiety, or other emotional symptoms (48-52%), and decreased sex drive (38%) (Dannels & Charlifue, 2004; n=230; Jackson & Wadley; n=472). Yet, an increase in spasticity, bladder spasm, and dysautonomia symptoms during menopause seem to be SCI-specific (Chiodo et al. 2007). It is possible that menopause symptoms can often be underreported in women with SCI due to symptoms’ similarity with SCI-related vasomotor conditions like autonomic dysreflexia and impaired temperature regulation (Briggs et al. 2022; Dannels & Charlifue 2004; Jackson & Wadley 1999; Pentland et al. 2002).
It has been suggested that care providers and women with SCI should carefully monitor symptoms during perimenopause and any treatment plan should reflect a joint decision between the woman and their healthcare providers (Charlifue & Dannels, 2004; n=230).
Vasomotor Symptoms
Vasomotor symptoms, or ‘hot flashes’, are among the most common symptoms experienced by women during menopause. In a case-control study, Kalpakjian et al. (2010; n=128) found a significant effect of menopause status in both women with and without SCI, that is, women in early post-menopause were significantly more bothered than those in late post-menopause (p=0.032). Contrary to hypothesis, women without SCI had significantly greater bother of vasomotor symptoms (p=0.020), though authors suggest that women with SCI may be more accustomed to temperature dysregulation, or their lack of sensation may have compromised the experiencing of symptoms.
In a large survey, Dannels and Charlifue (2004; n=230) found that amongst respondents (menopause-aged women with SCI), 40% reported night sweats and 39% reported hot flashes. There were no reported differences in this study between women with tetraplegia or paraplegia, or whether SCI was complete or incomplete. Authors suggest that perimenopause is uniquely challenging for women with SCI because the symptoms may mimic or mask other conditions associated with SCI, like autonomic dysreflexia, infections, impaired temperature regulation, and spinal cord cysts.
A small case series study (Dirlikov et al. 2019; n=27) found that time from injury was significantly associated with thyroid stimulating hormone (TSH) (r=.536, p=.015), such that greater time from injury was associated with elevated TSH levels.
Skin and Vaginal Changes
In a case-control study, Kalpakjian et al. (2010; n=128) found that menopause-aged women with SCI experience significantly diminished sexual arousal compared to their age-matched counterparts without SCI (p=0.012). In a large survey, Jackson & Wadley (1999; n=472) found that vaginal dryness was experienced by 27% participants and painful intercourse was experienced by 14% of their respondents. of women with SCI. Some reviews also noted that women with SCI might experience skin issues like skin flushing due to temperature dysregulation, as well as changes to the skin, like greater risk of pressure ulcers, due to estrogen deficiency (Jackson, 2001; Welner et al. 2002).
Mood, Cognition, Sleep Disorders, and Self-Management
Dannels & Charlifue (2004; n=230) reported that 43% had sleep disturbances and 40% had night sweats, and that there were no significant differences between women with tetraplegia or paraplegia or whether neurologically complete or incomplete. Abdullah et al. (2023; n=128) found that older females (>60 years) had greater improvement in Oswestry disability index (ODI) and Beck’s depression inventory scores (BDI) (both p<0.05). In a survey study, Jackson and Wadley (1999; n=472) found that common symptoms of menopause after injury included emotional liability (52%), depression (52%), anxiety (48%), and sleep disturbances (43%), and that mood disorders were reported more frequently after injury. Though a case-control study (Kalpakjian et al. 2010; n=128) found no significant main effect for menopause status on mood symptoms in either women with or without SCI. One small case series (Dirlikov et al. 2019; n=27) found a significant association was between time from injury and CES-D total score (r = −.547, p = .013), such that lower CES-D total scores were associated with greater time from injury.
Osteoporosis
It is difficult to tease apart the effects of age, menopause, and SCI on bone health, but some data have been contributed studying commonly aged participants that shed some light.
In a large survey study, Jackson and Wadley (1999; n=472) reported that new bone fractures were experienced by 2.8% of respondents after menopause prior to SCI, 4.4% experienced a bone fracture after menopause and post injury, but 30% of postmenopausal respondents who were injured before menopause had new fractures.
In a case-control study, Slade et al. (2004; n=37) found that trabecular bone microarchitecture in the distal femur were not different in postmenopausal versus the premenopausal women but were different in women with SCI versus women without SCI; women with SCI had 30.9% lower total trabecular volume and 61% greater total separation (both p<0.001). In addition, postmenopausal women with SCI had 33% greater trabecular spacing in the tibial area than pre-menopausal women with SCI (p=0.02; d=1.45) (Slade et al. 2004).
Hormone Replacement Therapy
Though commonly prescribed in women during menopause, little is known about how Hormone Replacement Therapy (HRT, or HT) interacts with SCI. In the only RCT we found re: women with SCI and menopause, Becker et al. (2009; n=176) tested a tailored intervention vs. a standard educational booklet and measured participants knowledge and satisfaction with their care. Both groups significantly improved their knowledge and decreased their decisional conflict and uncertainty about HT use. However, 72% of women in the tailored intervention group rated the materials they received as relevant to the concerns of women with physical impairments, compared with 59% in the comparison group (t=1.87, p<.05, 1-tailed). Women who reported actually seeing their provider during the study had significantly higher scores at the third data collection (t=3.25, p<.001). The same authors (Becker et al. 2002; n=167) found in a survey study that the intent and prediction to use HRT were significantly correlated to physician’s subjective norm re: HRT prescription, attitude scale, HRT self-efficacy rating, and difficult to decide rating (all p<0.05).
In a large survey, Jackson and Wadley (1999; n=472) reported that HRT was used by 35% of respondents preinjury and by 26% of respondents postinjury (26%), though half of these women reported that their menopausal symptoms were not alleviated by HRT. The results suggest that health care providers should provide specialized care, screenings and other preventive measures at a younger age, and that dialogue should consider broadly how menopausal changes affect the lives of women with disabilities (Becker et al. 2009).
Bladder
Studies that measured bladder issues in women with SCI around the stages of menopause usually found additional bother. In a case-control study, Kalpakjian et al. (2010; n=128; 62 women with SCI) found that women with SCI at menopausal age had a significantly higher number of bladder infections (p<0.001). In one survey, Elmelund et al. (2018; n=98) reported that 14% of participants had pelvic organ prolapse (POP) POP symptoms and 21% had anatomical POP stage ≥2. In this study, the group with POP stage ≥2 was significantly older, had more deliveries, more vaginal delivery, and more postmenopausal women, but the groups did not differ on median time after injury, neurological level, or completeness of injury. In addition, 71% experienced urinary incontinence, 27% experienced fecal incontinence, 63% experienced bladder emptying problems, and 70% experienced bowel emptying problems. In one of the first survey studies to report on menopause in women with SCI, Jackson and Wadley (1999; n=472) reported that 14% of participants reported frequent bladder spasms.
Larger studies are needed to examine menopause outcomes with respect to level of injury and completeness of injury (Kalpakjian, 2010). A review and recommendations for management of menopause in the general population was published in the Canadian Medical Association Journal in 2023. For health care providers, a treatment algorithm was developed with six specific questions to ask people in the general population experiencing menopause that could be useful if considered in the context of SCI.
Conclusion
There is level 1 evidence (Becker et al. 2009) that tailored educational support for women with SCI going through menopause significantly improves the relevancy of material and the participant knowledge, as well as decreasing decisional conflict about hormone replacement therapy use.
There is level 3 evidence (Kalpakjian et al. 2010) found that women with SCI undergoing menopause experienced greater bother of somatic symptoms (a sub-scale, p≤0.001), bladder infections (p≤0.001), and diminished sexual arousal (p=0.012).
