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Underdiagnosed & Undertreated: The Mysteries of Genitourinary Syndrome of Menopause

Underdiagnosed & Undertreated: The Mysteries of Genitourinary Syndrome of Menopause

Most women have never heard of genitourinary syndrome of menopause (GSM). But given its prevalence and progressive nature, many healthcare practitioners are working to increase attention and treatment.

The genitourinary syndrome of menopause is a new term that describes various menopausal symptoms and signs including not only genital symptoms (dryness, burning, and irritation), and sexual symptoms (lack of lubrication, discomfort or pain, and impaired function), but also urinary symptoms (urgency, dysuria, and recurrent urinary tract infections).

The condition is known by several names — including vulvovaginal atrophy — in part because the symptoms resulting from a lack of estrogen can range from sexual discomfort to frequent urinary tract infections. GSM occurs because of the natural decrease in estrogen in the vagina, vulva, and bladder that occurs with menopause. With declining estrogen, the vaginal tissue can become thinner and more easily irritated.

About 30-50% of postmenopausal women experience these symptoms. Unfortunately, though, women do not generally discuss these problems with their healthcare providers.

Stressed out woman

“GSM includes conditions of the vagina, vulva, pelvic floor tissues, urinary tract, and sexual dysfunction and loss of libido. Many women are reluctant to report these symptoms to their healthcare professional for many reasons.”

What are the symptoms of Genitourinary syndrome of menopause (GSM)?
  GSM symptoms are manifestations of the changes that occur during menopause and lead to complaints of the following: 

  • Vaginal dryness
  • Vaginal burning
  • Vaginal discharge
  • Genital itching
  • Burning with urination
  • Urgency with urination
  • Frequent urination
  • Recurrent urinary tract infections
  • Urinary incontinence
  • Light bleeding after intercourse
  • Discomfort with intercourse
  • Decreased vaginal lubrication during sexual activity
  • Shortening and tightening of the vaginal canal
  • Persistent or recurrent discharge with odour (not Candida in postmenopause)
  • Loss of clitoral stimulation
  • Pelvic floor weakening

Risk factors
Certain factors may contribute to GSM, such as:

  • Smoking: Cigarette smoking affects your blood circulation and may lessen the flow of blood and oxygen to the vagina and other nearby areas. Smoking also reduces the effects of naturally occurring estrogens in your body
  • No vaginal births: Researchers have observed that women who have never given birth vaginally are more likely to develop GSM symptoms than women who have had vaginal deliveries
  • No sexual activity: Sexual activity, with or without a partner, increases blood flow and makes your vaginal tissues more elastic

Complications associated with Genitourinary syndrome of menopause (GSM)

GSM is usually not dangerous, however if left untreated it can increase the risk for other medical problems.
 Women who have this condition have a higher probability of: 

  • Urinary problems:  Studies have linked vaginal atrophy to an alteration to the urinary system leading to urinary troubles. You may experience urgency of urination, increased frequency of urination or a burning sensation while urinating if you have vaginal atrophy. Some women experience more urinary tract infections or urinary incontinence
  • Vaginal infections:  Vaginal atrophy may lead to an alteration of acid balance of a vagina making such women with this condition more likely to acquire vaginal infection such as Bacterial Vaginosis (BV) which would then necessitate the need for a vaginal pH regulator
  • Sexual Problems:  Approximately 50-60% of post-menopausal women have vaginal atrophy symptoms that negatively impact on sexual function

What You Don’t Want to Talk About, But Should

The most bothersome symptoms reported with GSM are vaginal dryness and dyspareunia; some women have multiple symptoms, whereas others are asymptomatic. It is understandable that you may be feeling shy or embarrassed to talk about these symptoms, however, it’s a very important topic, and you’re by no means alone in your concerns. 

Did you know?
In the Women’s Health Initiative Study, 60% of participants had physical evidence of vaginal atrophy, but only 10% declared they had symptoms. Estimations suggest that only 7% of women are treated.1 Many women were unaware that there were treatments available.2 Symptoms after surgical menopause, treatment for breast cancer and premature menopause are often more severe and debilitating.

  1. Archer DF, Labrie F, Bouchard C, et al. Treatment of pain at sexual activity (dyspareunia) with intravaginal dehydroepiandrosterone (prasterone). Menopause 2015;22(9):950–63. Search PubMed  
  2. Nappi, M. Kokot-Kierepa. Women’s voices in the menopause: Results from an international survey on vaginal atrophy. Maturitas 2010;67(3): 233–38. Search PubMed

Regular sexual activity, either with or without a partner, may help prevent genitourinary syndrome of menopause. Sexual activity increases blood flow to your vagina, which helps keep vaginal tissues healthy.

Treatment will depend on the symptoms and signs, and the degree of severity.
Non-hormonal therapies include personal lubricants, vaginal moisturizers, and vaginal laser (long-term safety and efficacy have not been established). Hormonal therapies include vaginal estriol cream or pessaries, vaginal estradiol tablets, or systemic hormone therapy

Personal lubricants and vaginal moisturizers
Lubricants and vaginal moisturizers are effective in relieving discomfort, friction, and pain with penetrative sex. Lubricants are used at the time of intercourse, whereas vaginal moisturizers provide longer term relief. Lubricants can be water-based or silicone-based. Water-based lubricants are non-staining and have fewer side effects than silicone-based lubricants.

Moisturizers rehydrate dry tissues by changing the fluid content in the vaginal epithelium, absorbing, and adhering to it, mimicking vaginal secretions, and lowering the pH. The effect lasts about three days. Moisturizers, unlike lubricants, are designed for internal vaginal use and provide longer lasting relief of vaginal dryness, compared to lubricants.

Most women find that non-prescription personal lubricants and vaginal moisturizers work well, especially for mild symptoms.  These non-prescription treatments are hormone-free, have few side effects and are recommended by the Society of Obstetricians & Gynecologists of Canada (SOGC) as a first line treatment.  They are applied locally and act immediately.

Hormonal therapies

If non-prescription products are not effective, local vaginal estrogen is both a Health Canada and FDA-approved therapy that has proven to be effective as a second line option. 

Two types of estrogen are available: topical and systemic.

  1. Topical (vaginal) estrogen is applied to the surface of the vagina. Studies have shown that topical estrogen is a remarkably effective treatment. Topical treatment does not have the same health risks of systemic estrogen because only small amounts of estrogen reach the bloodstream.
  2. Systemic estrogen, also called hormone therapy, is taken as a pill, patch, gel, or spray. Systemic estrogen affects the whole body and has some health risks. If you have had breast cancer, talk with your doctor about what treatment is best for you. Limiting or avoiding estrogen can help prevent a return of breast cancer. Systemic estrogen, estrogen taken orally as in hormone therapy, should not be used for symptoms that involve vaginal atrophy only.

There are no studies on the long-term risks of vaginal estrogen preparations, but absorption is negligible once the atrophic changes are reversed. Added progestogens are not needed to prevent endometrial stimulation. The safety in breast cancer survivors is not established, especially with aromatase inhibitors, because of the possible risk of recurrence.3 In women with breast cancer, vaginal estriol preparations are prescribed on an individual basis, in consultation with the woman and her breast physicians, depending on symptoms and their impact on quality of life.

Newer treatments
Newer treatments are becoming available. Vaginal laser therapy is being trialled for vaginal dryness, but long-term data are not available.
Sexual dysfunction
Management of a woman with sexual dysfunction, including loss of libido, dyspareunia due to vulvovaginal atrophy and pelvic floor tension, requires a more complex and multidisciplinary approach. The severity of the symptoms will determine the therapies required. Lubricants and moisturizers may be recommended initially for dryness and loss of lubrication with intercourse while vaginal estrogens are prescribed when severe atrophic changes are present.
If there is pelvic floor dysfunction, pelvic pain or urinary symptoms, referral to a pelvic floor physiotherapist for pelvic floor training and relaxation will help to reduce symptoms. Sometimes, vaginal trainers will help dilate the vaginal introitus.
The good news! Tyros Biopharma has effective, non-hormonal treatment options for vaginal atrophy, recurrent UTIS and bacterial vaginosis. 
Happy elderly couple
Prompt treatment can keep problems from getting worse. 
Visit us here to learn more!