Exploring Hormone and Non-Hormone Treatments for Genitourinary Syndrome of Menopause
By Dr. Kara Dionisio
Naturopathic Doctor & North American Menopause Society Certified Practitioner
I’ll never forget the day my patient told me her vagina had “gone Gobi”. I wasn’t quite sure what she meant until she clarified, “Dr. Kara, like the Gobi Desert!”. She went on to explain how dry and uncomfortable it was “down there”, and how much it was impacting her life.
I was glad she told me (although, I would have asked anyway)…because while changes to the vagina, vulva and bladder happen to at least 50-85%1 of people around and after menopause, only 50% of people talk to their health care provider about it, and only 4% of those with symptoms are actually receiving standard treatment2. This is despite the availability of safe and effective options to treat this pervasive, persistent and progressing problem which is a result of declining estrogen after menopause.
It’s a silent epidemic.
Previously called “vulvovaginal atrophy” (yup, that one needed a rebrand), the new term “Genitourinary syndrome of menopause” or GSM (ok, slightly better?), at least acknowledges the triad of genital, sexual, and urinary changes that result from declining and eventually low levels of estrogen through the menopause transition and beyond.
Many experiences in the menopause transition are transient, that is, they come (sometimes with a roar), but over time they often improve as your body recalibrates to lower hormone levels (psst…don’t suffer through, we can help with these too!).
GSM often appears later than the other changes around menopause and it will continue to get worse over time.
The good news is that we have safe and effective approaches that work. YOUR best treatment approach will depend on severity of the symptoms, clinical factors, but mostly, your preference for method of application.
Hyaluronic Acid (HLA)
– An evidence-based, non-hormonal option, that the North American Menopause Society considers a “first line treatment” for GSM3
– Adheres and retains moisture in the wall of the vagina, providing a hydrating and lubricating effect
– In two recent systematic reviews, HLA was shown to improve vulvovaginal symptoms (such as painful intercourse, itching, burning, dryness) as well, or almost as well for some outcomes, as estrogen therapy4 5
Available Products: Gynatrof | Repagyn | Feel Amazing / Menopause Chicks Vaginal Moisturizer
Standard Application: As directed based on product type
Pros: Non-hormonal, over-the-counter. Effective on its own, or excellent in combination on alternate days from using estrogen therapy
Cons: Not covered by a drug plan
Low Dose Vaginal Estrogen Therapy
The vagina loves estrogen. In fact, the vagina, vulva, and lower part of the urinary bladder all contain an abundance of estrogen receptors. These little docking sites are waiting for estrogen to bind and affect numerous changes that keep the tissue healthy, moist, elastic and functioning optimally. The outcomes of using vaginal estrogen include reversing or improving most of the GSM symptoms indicated on the infographic! It generally starts working within a few weeks but can take up to 12 weeks for full effect.
Vaginal estrogen is a low-dose, local, and safe therapy for GSM that can be considered in most people for long-term prevention and treatment.
Many patients (and even doctors) still hold misinformation about the risks of estrogen. Even the package inserts for vaginal estrogen products are misleading, out-of-date, and extrapolate data from other types of hormone therapy (advocacy groups are trying to change this!).
Low-dose vaginal estrogen is not the same as systemic (whole-body) Hormone Replacement Therapy (HRT). The dosages of estrogen in vaginal products are very low, and except for a small brief initial rise in blood estrogen level, the hormone stays local to the area applied. It is generally safe for the lining of the uterus, which is why, unlike systemic HRT, progesterone therapy is generally not required to accompany its use. This makes vaginal estrogen a safe therapy for most people to use, and continue to use long-term. Patients with undiagnosed vaginal bleeding or a history of hormone-sensitive cancers need to consult with their healthcare professional.
A 2016 Cochrane review6 found no differences in the efficacy between the various types of vaginal estrogen products.
Please use the below chart as a reference to start getting familiar with the available products, standard dosing, and some potential benefits and drawbacks of each.
Hyaluronic acid and vaginal estrogen are first-line treatment approaches for most people, however, there are several other evidence-based treatment options you can discuss with your health professional. Some people decide to take Systemic HRT to help with symptoms of the hormone change at menopause (e.g. hot flashes, sleep, mood, bone and heart health). About 85-90% of people on systemic HRT will also gain benefit for GSM symptoms7. However, 10-15% will still require the addition of local treatment. Other evidence-based, yet less commonly used therapies, include vaginal DHEA (e.g. Prasterone / Intrarosa), vaginal laser therapy (e.g. Mona Lisa’s Touch), and newer drugs called SERMs (e.g. Ospemifene).
The BAD NEWS: MOST people post-menopause will experience some or many symptoms of GSM, that range from mild to severe…and left untreated, it just keeps getting worse over time
The GOOD NEWS: There are highly effective and safe treatment options
This information is intended to help you explore your options so that you can have informed discussions, and make shared decisions, with your health professional.
You and your vagina deserve it!
❤️ Dr. Kara
DISCLAIMER: This content is provided for informational purposes only and is not intended as medical advice or as a substitute for the medical advice provided by a doctor or other qualified medical professional.
You can find out more about all the menopause shenanigans Dr. Kara gets up to on her bio found HERE.
Dr. Kara & Associates see patients in-person and virtually, across Ontario. Visit our web site HERE.
Medical Practitioners excited to learn evidence-based hormone therapy prescribing can take Dr. Kara’s Advanced Practice Menopausal Hormone Therapy (MHT) course offered through The Confident Clinician – find out more HERE.
- Palma F, Volpe A, Villa P, Cagnacci A, study as the writing group of the A. Vaginal atrophy of women in postmenopause. Results from a multicentric observational study: The AGATA study. Maturitas. 2016;83:40-44.
- Waetjen LE, Crawford SL, Chang PY, et al. Factors associated with developing vaginal dryness symptoms in women transitioning through menopause. Menopause. 2018;25(10):1094-1104.
- (NAMS) TNAMS. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause. 2020;27(9):976-992.
- Buzzaccarini G, Marin L, Noventa M, et al. Hyaluronic acid in vulvar and vaginal administration: evidence from a literature systematic review. Climacteric. 2021;24(6):1-12.
- Santos CCM dos, Uggioni MLR, Colonetti T, Colonetti L, Grande AJ, Rosa MID. Hyaluronic Acid in Postmenopause Vaginal Atrophy: A Systematic Review. J Sex Medicine. 2021;18(1):156-166.
- Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Db Syst Rev. 2016;(8):CD001500.
- Archer DF. Efficacy and tolerability of local estrogen therapy for urogenital atrophy. Menopause. 2010;17(1):194-203.