“Speed” and “action” are required to halt the rise in cases, the UK’s chief scientific adviser warns.

• Not all women have the same level of pain during childbirth
• A study found that some women had higher pain tolerance for heat, cold and mechanical pressure
• These women had a higher-than-expected occurrence of a rare variant of the gene KCNG4

A genetic variant that acts as a natural pain reliever may explain why some women don’t require pain relief during childbirth, researchers say.

The level of pain and discomfort experienced during childbirth varies widely, so researchers at the University of Cambridge in England decided to investigate why some women have less pain during labour and delivery.

“It is unusual for women to not request gas and air, or epidural for pain relief during labour, particularly when delivering for the first time,” said co-lead author Dr Michael Lee, a consultant in pain medicine in the Division of Anaesthesia.

“When we tested these women, it was clear their pain threshold was generally much higher than it was for other women,” he said in a university news release.

A rare genetic variant

Lee and his colleagues assessed women who didn’t request any pain relief during an uncomplicated vaginal delivery of their first baby. To test their pain threshold, researchers applied heat and pressure to their arms and had them plunge their hands into icy water.

Compared to a control group of women who required pain relief when giving birth, women in the test group had higher pain tolerance for heat, cold and mechanical pressure.

No differences were found in the groups’ emotional and thinking abilities, suggesting a difference in their ability to detect pain.

Genetic tests on both groups of women found that those in the test group had a higher-than-expected occurrence of a rare variant of the gene KCNG4. About one in 100 women have this variant.

This variant limits the ability of nerve cells to send pain signals to the brain, according to authors of the study published on 21 July in the journal Cell Reports.

New drugs to manage pain

“The genetic variant that we found in women who feel less pain during childbirth leads to a ‘defect’ in the formation of the switch on the nerve cells. In fact, this defect acts like a natural epidural,” said study senior co-author Ewan St John Smith, a group leader in the Department of Pharmacology.

“It means it takes a much greater signal – in other words, stronger contractions during labour – to switch it on. This makes it less likely that pain signals can reach the brain,” Smith said in the release.

Researchers said they hoped the discovery would lead to development of new drugs to manage pain.

“This approach of studying individuals who show unexpected extremes of pain experience also may find wider application in other contexts, helping us understand how we experience pain and develop new drugs to treat it,” said study senior co-author Dr David Menon, head of the Division of Anaesthesia.

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• Genitourinary syndrome of menopause includes vaginal dryness, painful sex and painful urination
• This affects most postmenopausal women
• It’s best to try over-the-counter products first as prescription medicines can be costly

Hot flashes and night sweats are well-known side effects of menopause, but the end of a woman’s periods can also lead to other uncomfortable changes.

Vaginal dryness, painful sex and painful urination are common symptoms of genitourinary syndrome of menopause, or GSM. Estimates vary, but most research suggests that a majority of postmenopausal women are affected. It can significantly impair health, sexual function and quality of life.

But women experiencing these symptoms may not know why they’re happening or that treatments are available. In recent years, new therapies have been approved, and the North American Menopause Society (NAMS) has now published new treatment recommendations after reviewing those therapies.

Best to ‘start simple’

Deciding which to use starts by “knowing what you’re treating,” said Dr Anne Ford, an obstetrician-gynaecologist at Duke University Medical Center in Durham, North Carolina.

When counselling her patients, Ford recommends “starting simple, and then getting more complex”, which dovetails with the NAMS guidelines.

NAMS recommends over-the-counter products like moisturisers and lubricants first. If these options don’t help, prescription therapies can deliver oestrogen or other hormones directly to the vagina in the form of creams, rings, tablets and inserts.

Oral oestrogen therapy can be considered if vaginal symptoms are accompanied by debilitating side effects, such as hot flashes and insomnia. Still, the potential health risks associated with hormone therapy make it a backup option, NAMS says.

GSM used to be called vulvovaginal atrophy, to describe when tissues outside and inside the vagina become thinner, drier and less flexible due to less oestrogen. The new moniker GSM “acknowledges that the symptoms were more than just vaginal and that they really included urinary symptoms”, said Dr Stephanie Faubion, medical director for NAMS.

Pain during sex

Adding the word menopause served to help women who didn’t recognise that these symptoms were related, she added.

While pain during sex is a common complaint, Faubion said the idea that the condition only affects sex is a misconception.

“We’re talking about this not just in the context of sex, but in the context of women being comfortable,” Faubion said. For example, wiping with toilet paper or wearing jeans can bring pain.

Ford explained that when NAMS recommends starting with “simple” treatments, it is referring to over-the-counter moisturisers and lubricants. If the discomfort is mostly external, moisturisers can be applied to the vulva. “Moisturisers aren’t really made for sex. They’re made for if people have discomfort in their day-to-day life due to the dryness,” she noted.

Prescription treatments expensive

For women who are experiencing pain during sex, over-the-counter lubricants can provide relief, Ford added.

Prescription treatments can be costly and may not be covered by insurance, which is why women are urged to try over-the-counter remedies first.

But sometimes these products don’t do enough. The symptoms of dryness and pain are side effects of the vaginal tissues thinning and losing elasticity, and only hormonal therapies can treat the problem itself.

“If we get to the point where I think a prescription-based product is indicated, then I talk to the patient about their preferences and go over all the different kinds of products that are available,” Ford said. “There are creams, rings, vaginal inserts and suppositories, and there’s now a tablet – the ospemifene tablet.”

Oestrogen delivered vaginally provides sufficient hormone to relieve symptoms and is preferred over more aggressive oestrogen treatment when the symptoms are centralised in the vaginal area, according to the NAMS recommendations.

Vaginal oestrogen products are typically low-dose. Some, such as the DHEA vaginal insert, are not specifically oestrogen-based, but work by increasing certain hormone levels.

Systemic hormone therapy

“If the patient really has pain on the inside of the vagina, then anything that you put in the vagina will help that – whether it’s the ring, the cream or the inserts – all of that stuff will probably help the internal discomfort,” Ford said.

The oral drug, ospemifene (Osphena, Senshio), is approved to treat vaginal dryness and painful sex. Due to potential health risks, including endometrial cancer, all other systemic oestrogen therapies are only recommended if additional menopause-related symptoms are present.

“If I had somebody who came in and said that they weren’t sleeping because they were having 20 hot flashes at night, they were irritable, their depression was getting worse, and it was so horrible that they just couldn’t live like this – and they had vaginal pain – that’s somebody who would try systemic hormone therapy,” Ford said.

Energy-based devices, including lasers, may one day be added to the treatment arsenal. Lasers are thought to work by inducing collagen production, thereby thickening the skin.

But, Faubion said, “While initial results are really promising, we still await the longer-term studies to make sure that these are safe and effective for women over the long haul.”

The new NAMS position statement was published online in the September issue of Menopause: The Journal of The North American Menopause Society.

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The warning comes as people in England who refuse an order to self-isolate could be fined up to £10,000.

Options include a ban on households mixing in England, as a further 4,422 UK cases are confirmed.

Patients say they have missed out on face-to-face examinations and appointments.

• Not all eczema treatments can be given to young children
• In a study, a topical probiotic against eczema was tested on children, with good results
• This fits in with evidence that eczema involves an imbalance in the skin’s microbiome

Applying a type of “good” bacteria to the skin may relieve children of the itch and discomfort of eczema, a new, small study suggests.

Eczema is a chronic inflammatory condition that causes dry, itchy skin and scaly rashes. It usually starts in early childhood, and commonly occurs along with allergies like hay fever and asthma, according to the American Academy of Allergy, Asthma and Immunology.

There are numerous treatments for eczema, both topical and oral, but not all can be given to young kids.

“So, there’s a big need for safe and effective treatments for young children,” said study author Dr Ian Myles. He is a researcher and staff clinician with the US National Institute of Allergy and Infectious Diseases.

Imbalance in microbiome

For the study, his team tested a topical probiotic against eczema in 20 children as young as three years of age. Over four months, 17 of the 20 saw their rashes and itchiness fade by more than 50%.

The children were also able to cut down on topical corticosteroids, a standard treatment for eczema – but one that can cause side effects like thinning of the skin and stretch marks.

The probiotic therapy is a spray solution containing live Roseomonas mucosa bacteria. Those microbes are normally present on the skin, and past research has found that R. mucosa from people with healthy skin can treat eczema in lab mice.

In contrast, samples of the bacteria from people with eczema either had no effect, or made the skin condition worse.

It all fits with evidence that eczema involves an imbalance in the skin’s microbiome. That refers to the vast array of bacteria and other microbes that naturally dwell on the skin and help maintain its health.

Staph infections

The skin, Myles explained, has to repair itself from daily wear-and-tear, and the microbiome assists in that. He said R. mucosa appears to produce oils that aid the skin’s repair capacity.

The treatment also reduced staph bacteria on the children’s skin, and those microbes can worsen eczema symptoms.

Dr John Browning, a paediatric dermatologist, said, “I think this is a really interesting study.” Browning was not involved in the research.

He said people with eczema often get staph infections and need antibiotic treatment. It’s possible R. mucosa could be an alternative, according to Browning, who is based at Children’s Hospital of San Antonio and Texas Dermatology and Laser Specialists.

The findings, published online on 9 September in the journal Science Translational Medicine, are based on 20 children and teenagers who were given the probiotic therapy for four months. They (or their parents) applied the spray solution twice a week for three months, and then every other day for the final month.

Lasting benefits

On average, Myles said, the kids’ itchiness and rash improved by 60% to 75%, with no significant side effects.

And there were signs it could have lasting benefits. Eight months after the therapy was stopped, the good bacteria were still colonising the children’s skin – indicating R. mucosa had “moved in,” Myles explained.

That, he said, suggests the therapy could be one time only. It would still be possible, though, that whatever caused the bacterial imbalance in the skin could do it again.

Myles said a broader goal is to figure out what those factors are – with diet, soaps and antibiotics being among the suspects.

Browning is part of another trial testing R. mucosa for treating eczema. But he does not think it is the only bacterium that matters.

Further development

“There could be a lot of variability patient to patient in whether this approach would be helpful,” Browning said.

Myles agreed, noting that not all study patients responded to the probiotic.

It’s unclear when the R. mucosa therapy could become commercially available. The US National Institutes of Health has licensed it to a private company, Forte Biosciences, to further develop.

Myles said the company worked to freeze-dry the probiotic so it can be reconstituted with water, then sprayed on. That will make it shelf-stable.

“We anticipate this being something you can pick up at the pharmacy,” he said.

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