Genitourinary Syndrome of Menopause

Genitourinary syndrome of menopause (GSM) is caused by decreases in estrogen and other sex steroid levels; however, other causes of low estrogen can cause similar symptoms (eg, during lactation or treatment with aromatase inhibitors) (1).

In the past, numerous terms, like vulvovaginal atrophy, were used to describe the physical changes that occur after menopause. However, these terms were inadequate because they did not reflect symptomatology. The umbrella term GSM encompasses structural changes in the vulvovaginal epithelium, clitoris, vaginal smooth muscle, and vulvovaginal anatomy as well as changes such as slower nerve conductivity, and reduced blood flow (2, 3).

Symptoms resulting from the effect of estrogen deficiency on the genitourinary tract may include the following (1):

• Vulvovaginal discomfort with dryness, irritation, and/or pruritus

• Vaginal dryness and decreased lubrication contributing to pain or bleeding with vaginal penetration

• Urinary symptoms (eg, urgency, frequency, dysuria, recurrent urinary tract infections)

Pelvic examination findings may include thinning of the vaginal epithelium; loss of tissue elasticity; smooth muscle atrophy; clitoral fibrosis; narrowing of the vaginal introitus; and shortening of the vaginal canal.

It is important to highlight that symptoms due to GSM can occur in the absence of physical signs, and the converse is true as well: signs may be present in asymptomatic individuals.

• Medical history

• Pelvic examination

The evaluation of GSM includes a thorough history and a comprehensive pelvic examination. (See table Components of the Sexual History for Assessment of Female Sexual Dysfunction.) Pelvic examination should assess for signs of atrophy, vaginitis or other infection, neoplasm, prolapse, or dermatologic changes (1). Laboratory testing is typically not warranted; however, if menopausal status is unknown, checking serum follicle stimulating hormone (FSH) and estradiol may be informative.

Suspicious lesions or worrisome dermatologic changes should be biopsied, and evaluation for infectious etiologies should be performed if history or symptoms are suggestive.

• Vaginal lubricants and moisturizers

• Vaginal hormone therapy (low-dose estradiol or dehydroepiandrosterone)

• Ospemifene

The treatment of GSM focuses on alleviation of symptoms and must be continued indefinitely, as the condition is chronic. Discontinuation of treatment often results in recurrence of symptoms. For some menopause-related symptoms, like vasomotor symptoms or mood swings, resolution may occur without treatment; however, symptoms due to GSM rarely improve without treatment and may worsen over time.

Initial treatment of mild symptoms is typically with over-the-counter vaginal moisturizers and lubricants (1). Vaginal moisturizers create a temporary moisture barrier by adhering to the vaginal mucosa; therefore, frequent application at least 2 to 3 times per week is necessary regardless of sexual activity (2). Lubricants, on the other hand, are applied to the vaginal walls, penis, or device to reduce friction as needed during or in preparation for vaginal penetration. Clinicians should also counsel on the harms of using feminine hygiene products containing alcohol, fragrances, or preservatives (eg, like douches, soap, wipes or scented panty liners) that commonly trigger or exacerbate symptoms.

For persistent mild symptoms or patients that present with moderate to severe symptoms, pharmacologic therapies should be considered. First-line treatment includes local, low-dose vaginal estrogen therapy (ET) options; prasterone, an intravaginal dehydroepiandrosterone (DHEA) insert; or ospemifene, an oral selective estrogen receptor modular (SERM) (see table Treatment Options for Genitourinary Syndrome of Menopause) (3).

For women receiving systemic menopausal hormone therapy (MHT) to treat systemic menopausal symptoms and effects (eg, vasomotor symptoms, prevention of osteoporosis), GSM symptoms may not be addressed sufficiently. Therefore, if GSM symptoms persist while taking systemic MHT, local, low-dose vaginal ET may be added or the MHT regimen may be changed to include a systemic-dose vaginal estradiol ring.

While endometrial protection with a progestogen or SERM, is always required when systemic ET is used in women who have not had a hysterectomy, the same is not true for use of local, low-dose ET (3). Addition of a progestogen is not necessary with use of local, low-dose ET, even when the uterus is intact, because systemic absorption is negligible (4). Minimal systemic absorption is also the reason local, low-dose ET is not associated with elevated thromboembolic or oncologic risk (1, 3, 5, 6).

• Genitourinary syndrome of menopause (GSM) results from decreased estrogen and other sex steroids, causing changes in the genitourinary tract.

• Symptoms include genital dryness, burning, and irritation; decreased lubrication and dyspareunia; and urinary symptoms such as urgency, dysuria, and recurrent urinary tract infections.

• Diagnosis is based on history and pelvic examination; findings may include vulvovaginal atrophy, reduced elasticity, and anatomic changes.

• Treatment is ongoing and focuses on symptom relief, including vaginal moisturizers and lubricants and, for persistent or moderate or severe symptoms, local low-dose vaginal hormone therapies or other pharmacologic options.