Genitourinary Syndrome of Menopause (GSM)

Genitourinary syndrome of menopause (GSM), previously referred to as vulvovaginal atrophy (VVA) or atrophic vaginitis, is a common symptom of menopause. It may be present in perimenopause, but is more likely to become apparent as women progress through their menopause journey. Unlike vasomotor symptoms of menopause which will improve with time, genitourinary problems often persist and progress due to prolonged hypoestrogenism.

GSM is one of the most consistently identified predictors of sexual dysfunction in women, but is often underdiagnosed and undertreated. Many women do not voluntarily discuss these symptoms with their healthcare provider, and many healthcare professionals do not ask patients about it directly.

While the exact prevalence rates vary depending on the source it is estimated that between 36% and 84% of women in perimenopause and menopause will experience genitourinary symptoms.

GSM refers to a syndrome of defined signs and symptoms related to hypoestrogenic changes of the female genitourinary tract. The symptoms of GSM are directly related to the reduction in circulating estrogen levels after menopause. An abundance of estrogen receptors are present in the vagina, vulva, pelvic floor muscles, urethra, and bladder. As a result of the estrogen deficiency that occurs in menopause, both histological and anatomical changes occur in urogenital tissues. These changes lead to a thinning of the vaginal mucosa, reduced vaginal elasticity, increased vaginal pH leading to changes in the normal vaginal flora and decreased lubrication, all of which leave the tissues vulnerable to irritation, infection and trauma.

Symptoms include:

• Vaginal and vulval irritation, itching, burning or discomfort

• Urinary symptoms of urgency, frequency, nocturia and dysuria

• Recurrent urinary tract infections

• Lack of lubrication and pain during intercourse

• Light bleeding related to local trauma (for example insertion of a pessary)

Diagnosis is made based on the patient’s history and examination. As mentioned above, patients may not willingly disclose these symptoms and so healthcare providers should actively ask about them. An examination is important to rule out other causes of vaginal discomfort including Lichen Sclerosis, Lichen Planus, vulval dermatoses and malignant conditions. Signs of GSM include changes in tissue colour (ranging from pallor to inflammation), loss of elasticity, friable tissue that easily bleeds, petechiae and vaginal discharge.

For most women, further investigations are not necessary. If a vaginal discharge is present a high vaginal swab may be done to rule out candidiasis, bacterial vaginosis and sexually transmitted infections. Cervical smear tests should be kept up to date, although the smear taker should be mindful that the procedure may be traumatic to local tissues and extra lubrication may be required. Urinalysis may be required in patients presenting with urinary symptoms and a microscopy and culture should be considered for women experiencing recurrent urinary tract infections. Any abnormal vaginal bleeding should be investigated as appropriate. Treatment of GSM is vital in order to restore normal function of the urogenital tissues as well as to alleviate these very bothersome symptoms and improve quality of life. As the primary cause of these symptoms is a lack of estrogen, local estrogen therapy and/or systemic HRT would be considered the most logical first line therapy unless there is a contra-indication. It is important to note that local estrogen therapy is not considered to be HRT as it has little to no systemic absorption. The NICE Guidelines are quite clear that vaginal estrogen should be offered to women with GSM, even if on systemic HRT, and that it should be continued for as long as needed to relieve symptoms. It can and should be considered in women in whom systemic HRT is contraindicated, after seeking advice from a menopause specialist.

Local estrogen replacement can restore vaginal pH and helps to thicken and revascularise the vaginal epithelium. Vaginal estrogen use is also associated with a reduction in urinary symptoms and a decreased incidence of urinary tract infections. Vaginal estrogen can be absorbed from the vagina and surrounding area via a pessary, cream, gel or vaginal ring. There are two types of estrogen used – estradiol and estriol. Time to respond to therapy will depend on the degree of atrophic changes present when starting. Women with severe symptoms may only notice an improvement after several months. For many women, symptoms will return once the treatment is stopped, and so it is both safe and reasonable to continue vaginal estrogen therapy long-term.

Systemic HRT will very effectively treat genitourinary symptoms in women who have other menopausal symptoms and in whom HRT is not contra-indicated. Systemic HRT may also be used together with vaginal estrogen in those women who have persistent symptoms of GSM.

Non-hormonal treatments may be used alongside, or in place of, hormone therapies. They do not restore normal vaginal physiology. They are a good treatment option for women with mild symptoms, or for those women that do not want to use hormonal treatment. Vaginal moisturisers, used on a regular basis, may offer relief from symptoms of vaginal dryness. They help to retain moisture in the mucosa and may balance the vaginal pH. They should be used regularly for maximum benefit. Vaginal lubricants are intended for use with any sexual or penetrative activity, including speculum exams. Care is needed in selecting preparations which are appropriate for the vaginal environment and free of potential irritants such as glycerol. There are a wide variety of over the-counter products available and these may be water, oil, or silicon based. Patients should be advised that oil-based lubricants may negatively affect condom integrity. Vaginal laser therapy should not be offered to patients, as studies have shown no benefit over placebo.

Patients may require referral to a pelvic floor physiotherapist who can assist with treatment of vaginismus and hypertonicity, pelvic floor dysfunction, and the use of vaginal dilators if appropriate.

Other general recommendations for patients with GSM would be around minimising vaginal irritation. This can include wearing cotton underwear, avoiding very tight underwear and trousers, washing with warm water only and to avoid the use of soaps, bubble baths and feminine hygiene sprays.

In conclusion, genitourinary symptoms of menopause are common, bothersome and under discussed by both patients and doctors. Healthcare providers should actively ask about symptoms, and should feel reassured that local estrogen therapy can be safely prescribed in almost all menopausal women with GSM. Systemic HRT may be offered to women who have other menopause symptoms and do not have contraindications to use. Vaginal moisturisers and lubricants can be helpful adjuncts to hormone therapy, or may be used alone in women with mild symptoms or who do not wish to use hormonal treatments.