Genitourinary Syndrome of Menopause

Many women experience discomfort in the peri- and post-menopausal period.  The complaints vary but may include vaginal dryness and irritation, painful intercourse, lack of sensation with intercourse, leaking of urine, urinary urgency, recurrent urinary and vaginal infections, and even vaginal bleeding.  The changes that occur are due to declining estrogen levels and estrogen receptor levels in the vagina and lower urinary tract.  Without estrogen, the vaginal walls become thin, less plump or collagenized and easily irritated. The pH of the vagina changes as well increasing the chances of vaginal and urinary tract infection.

This complex of symptoms was previously known as postmenopausal atrophic vaginitis or vulvovaginal atrophy. In 2014 The North American Menopause Society (NAMS) began renamed it the genitourinary syndrome of menopause (GSM) to more accurately it.  Patients who are breastfeeding or have undergone chemotherapy may have similar symptoms.

Once a diagnosis of GSM has been established, there are a few treatments options I review. First, I offer over- the-counter remedies such as personal lubricants that can be used during intercourse. Water- based, oil-based and silicone-based lubricants are all safe to use with latex condoms and may provide adequate relief of symptoms.  Otherwise, I discuss adding a twice weekly over-the-counter personal moisture product. Patients may also achieve relief with homeopathic remedies including Vitamin E suppositories, coconut oil or aloe vera.

The second treatment option is vaginal estrogen products available with a prescription. These include conjugated estrogen or estradiol vaginal cream or estradiol tablets used twice weekly or the estradiol vaginal ring which that may be left in place for 3 months. The 2017 hormone therapy position statement of NAMS states that estrogen therapy is the most effective treatment for GSM.  The statement also reassures us that the FDA approved preparations result in minimal absorption into the bloodstream. This is important as many women are fearful of the potential risks of using estrogen. The latest data suggest that vaginal estrogen may be used in women with a history of breast cancer after a discussion with their oncologist.

Non-estrogen therapies that are approved for treating  GSM include ospemifene which is a daily oral selective estrogen receptor modulator (SERM) and a daily intravaginal dehydroepiandrosterone (DHEA) suppository.

A fourth therapy is now available. A CO2 laser can now be used to revitalize the vaginal mucosa adding collagen, elasticity and lubrication. This 10-minute office procedure is virtually painless with little to no downtime required. A series of 3 treatments 1 month apart are required to achieve optimal collagen production and remodeling in the vagina. The beneficial effects can last 1-2 years with the option of a single session yearly to maintain benefits.

Women who are experiencing these symptoms should be aware that they are very common and that there are options available for treatment.