Genitourinary Syndrome of Menopause

What is Genitourinary Syndrome of Menopause (GSM)?

Genitourinary syndrome of menopause, also known as GSM, is a recent term that defines several menopausal signs and symptoms connected with physical changes of the vagina, vulva, and lower urinary tract. The GSM comprises not only genital symptoms (irritation, burning, or dryness) and sexual symptoms (pain or discomfort, lack of lubrication, and impaired function), but also urinary symptoms (dysuria, urgency, and recurrent urinary tract infections). Doctors commonly use the term "genitourinary syndrome of menopause" to describe vaginal atrophy and its accompanying symptoms.

Signs and Symptoms

Some of the common signs and symptoms associated with genitourinary syndrome of menopause include:

Pain or discomfort during sex
Post-coital bleeding
Genital dryness
Reduced lubrication during sex
Burning, irritation, or itching of the vagina or vulva
Urinary urgency and frequency
Painful or burning urination
Reduced arousal, desire, or orgasm
Pallor or erythema
Urethral prolapse
Reduced vaginal elasticity

Causes

The most common cause of genitourinary syndrome of menopause is the reduction of estrogen levels. A reduction in estrogen level may occur due to:

Menopause
Perimenopause (years leading up to menopause)
Surgical removal of both ovaries (surgical menopause)
Hyperprolactinemia (during breast-feeding)
Chemotherapy
Radiation therapy
Side effect of breast cancer hormonal treatment
Ovarian failure secondary to pelvic radiation
Medications that affect estrogen levels, such as birth control pills

Risk Factors

Some of the factors that may contribute to GSM include:

Smoking: Smoking has been linked with reducing the effects of estrogens in the body and affects blood circulation to vaginal areas leading to vaginal atrophy.
No sexual activity: Sexual activity, with or without a partner, enhances blood flow and elasticity of the vaginal tissues.
No vaginal births: As per research data, women who have never had a vaginal birth are more prone to develop GSM.
Lack of exercise and alcohol abuse

Diagnosis

Diagnosis involves a thorough review of your medical history and symptoms and a general physical examination. Your doctor may also order specific tests, such as:

Pelvic exam – during this examination, your doctor feels your pelvic organs and visually examines your external genitalia, vagina, and cervix
Urine test - collecting and testing your urine sample to look for signs of urine infection that is causing urinary symptoms
Acid balance test – collecting a sample of vaginal fluids or putting a paper indicator strip in the vagina to assess its acid balance
Rectal exam to check for rectal mass and rectocele
Transvaginal ultrasound/hysteroscopy to visualize internal structures to check for any abnormalities
Wet mount to check for the presence of leukocytes and deficiency of lactobacillus
Pap test to look for atrophy of the cervix and narrowing of the cervical opening
MRI/CT scan to look for growths and pelvic abnormalities

Treatment

The primary objective of the treatment is to relieve symptoms associated with genitourinary syndrome of menopause.

As a first-line of therapy, your doctor may recommend lifestyle modifications and over-the-counter treatment options, such as:

Vaginal moisturizers to restore moisture to the vaginal area and improve elasticity
Water-based lubricants that is applied before sexual activity to reduce discomfort during intercourse

If these options do not ease your symptoms, your doctor may recommend topical estrogen. Vaginal estrogen comes in many forms and include:

Vaginal estrogen cream that is inserted directly into the vagina with an applicator
Vaginal estrogen suppositories which are low-dose estrogen suppositories inserted into the vaginal canal
Vaginal estrogen ring, which is a soft, flexible ring that is inserted into the upper part of the vagina to release a consistent dose of estrogen for a period of about 3 months.

Other treatment options that may be discussed include:

Selective Estrogen Receptor Modulators (SERMs): Another treatment option for GSM is selective estrogen receptor modulators (SERM), such as ospemifene. This is available in a pill form and is taken daily to relieve moderate to severe GSM symptoms. This is given only to women with no history of breast cancer and who are not at risk of developing breast cancer.

Vaginal Dehydroepiandrosterone (DHEA): These are vaginal inserts that deliver the hormone DHEA directly into the vagina to help mitigate painful sex. DHEA helps in producing other hormones, including estrogen.

Topical lidocaine: This is available as a prescription gel or ointment and can be used to reduce discomfort associated with sexual activity. This needs to be applied 5 to 10 minutes before sex.

Vaginal dilators: This is a non-hormonal treatment option and may be used in addition to estrogen therapy. The device stimulates and stretches the vaginal muscles to reverse narrowing of the vagina.

Vaginal/Vulvar C02 laser therapy: Mona Lisa Touch (MLT) is a treatment option for women who prefer to avoid estrogen. This procedure stimulates the vaginal tissue to produce collagen and promote blood flow to restore vaginal lubrication and elasticity. At this time, this treatment is recommended only for women with vaginal and vulvar dryness and pain. Women in prior studies experiences no side effects. They also experienced improvement in symptoms with each subsequent treatment. No long-term studies have been performed. Patients should expect to return every year for one maintenance treatment.