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 Table of Contents 
EDITORIAL
Year : 2019  |  Volume : 10  |  Issue : 3  |  Page : 111-113  

Genitourinary syndrome of menopause


Division of Gynaecologic Oncology, Prayaas Clinic; Eternal Heart Care Centre and Apex Hospital, Jaipur, Rajasthan, India

Date of Web Publication17-Sep-2019

Correspondence Address:
Dr. Ranu Patni
Division of Gynaecologic Oncology, Prayaas Clinic; Eternal Heart Care Centre and Apex Hospital, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmh.JMH_125_19

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How to cite this article:
Patni R. Genitourinary syndrome of menopause. J Mid-life Health 2019;10:111-3

How to cite this URL:
Patni R. Genitourinary syndrome of menopause. J Mid-life Health [serial online] 2019 [cited 2019 Dec 12];10:111-3. Available from: http://www.jmidlifehealth.org/text.asp?2019/10/3/111/267040




   The Story of Mrs. X: One of Many Top


Mrs. X, despite all her conscious efforts, could not enjoy the weekend celebration which her spouse's friends had organized for both of them as an anniversary gift! When their friends gave this as a surprise gift to them, both of them gratefully accepted it and were actually very excited to spend some quality time together. In fact, Mrs. X thought that this was a perfect opportunity to rejuvenate their 30-year-old married life! The resort was beautiful, the environment serene, the food awesome, and her spouse in his usual chirpy mood. However, persistent discomfort in her perineal region, constant itching, frequency of micturition, and dysuria continuously troubled Mrs. X. As if this was not enough, her dyspareunia strained their mood and the holiday ended abruptly before the weekend was over! Although she tried to discuss her problems with her spouse, he also could not understand them fully. Mrs. X had had her menopause 6 years back and was suffering from these symptoms for the last 1 year. She discussed these with her family physician but was not given any definitive advice. Now, her quality of life had started getting significantly affected.

The story of Mrs. X is not hers alone. There are millions of postmenopausal women who suffer from a condition called genitourinary syndrome of menopause (GSM).


   Genitourinary Syndrome of Menopause: Nomenclature Top


Earlier names for this condition were vaginal atrophy, vulvovaginal atrophy (VVA), and atrophic vaginitis. The term GSM was coined at a 2013 terminology consensus conference by The International Society for the Study of Women's Sexual Health and North American Menopause Society. GSM describes the genital, sexual, and urinary changes in the lower genital tract associated with menopause. It describes the constellation of lower urogenital tract signs and symptoms associated with a low-estrogen state.[1]


   Pathophysiology Top


The female genital tract and lower urinary tract share a common embryonic origin, both arising from urogenital sinus. Hence, both are affected by estrogen deficiency after menopause.[2] Estrogen receptors (both α and β) are present in the lower urogenital tract. Their levels decline with menopause and may be restored by estrogen treatment.[3] Estrogen deficiency after menopause causes reduction in the content of collagen, hyaluronic acid, and elastin, leading to thinning of epithelium, alterations in function of smooth muscle cells, and increase in the density of connective tissue and fewer blood vessels. These changes reduce elasticity of the vagina, increase vaginal pH, lead to changes in vaginal flora, diminish lubrication, and increase vulnerability to physical irritation and trauma.[4] Pathophysiologically, evidence shows that both circulating estradiol and its androgen precursors dehydroepiandrosterone (DHEA)/DHEA sulfate, androstenedione, testosterone, as well as their local metabolites, are vital to maintain normal structures and function of the vagina and surrounding urogenital tissues.[5]




   Prevalence and Diagnosis: the Dilemma Top


Affecting nearly 50% of postmenopausal women, GSM also occurs in other low-estrogen states, such as postpartum, during lactation, and with certain medications, such as aromatase inhibitors (AIs).[6]

GSM is a chronic condition which does not reverse by itself, requires individualized management, and definitely affects the quality of life of the patient (and her spouse) if not treated adequately.

The majority of postmenopausal women have signs of VVA upon physical examination but less than half of the postmenopausal women report VVA symptoms as bothersome in international surveys.[7] There is a lack of understanding surrounding vaginal health [8] and elderly women do not discuss VVA symptoms so easily because sexual health is a sensitive topic.[9] In addition, the condition is believed to be transient and part of the aging phenomenon.[10] A study by Sinha and Ewies showed that only a few women attributed symptoms to menopause or hormonal changes, most women do not consult a gynecologist about their symptoms, considering them to be part of normal aging.[11] Gupta et al. studied the prevalence and severity of urogenital complaints in postmenopausal women at a tertiary care hospital in Delhi, India. A total of 200 postmenopausal women (two groups: Group A - less than 5 years postmenopausal, Group B - more than 5 years postmenopausal) were screened and followed for urogenital complaints over 1 year. They found that the overall prevalence of urogenital symptoms was 67%. The most common symptoms were vaginal dryness (Group A - 62%, Group B - 48%), vaginal discharge/infection (Group A - 28%, Group B - 25%), and dysuria (Group A - 15%, Group B - 13.6%) in that order.[12]

The Study of Women's Health Across the Nation in the USA reported that women with sexual dysfunction considered vaginal dryness to be an important factor associated with masturbation, pain, arousal, physical pleasure, and emotional satisfaction.[13] VVA symptoms have an approximately linear relationship with sexual functioning,[14] and VVA correlates with sexual inactivity in the Hormone Therapy (HT) Trials of the Women's Health Initiative.[15]


   Management Options Top


The primary aim of treatment of GSM is relief of symptoms. Lifestyle changes and nonhormonal and hormonal treatments are the main options. Tobacco abuse has been associated with increased atrophic vaginal changes as well as menopause at younger age.[16] Apart from avoiding tobacco consumption, regular sexual activity, maintaining vaginal hygiene, and avoiding use of chemicals/fragrances in and around perineal area might also help to a certain extent.

Nonhormonal therapies for GSM include vaginal lubricants and moisturizers. These may be sufficient for patients with only mild symptoms. Other nonhormonal options such as black cohosh or soy have not been shown to improve GSM.[17]

Vaginal estrogen is still the gold standard pharmacologic treatment for GSM, especially for patients who are not suffering from systemic symptoms of menopause.[18] If systemic HT does not provide relief after a certain time, vaginal estrogens may be added to that too.

Vaginal estrogen users had similar rates of endometrial cancer, invasive breast cancer, and pulmonary embolism/deep vein thrombosis as nonusers. In fact, risks of coronary heart disease, fracture, and all-cause mortality were lower in vaginal estrogen users.[19] Addition of progestins is not required with low-dose vaginal estrogen use. Contraindications to vaginal estrogen use include unexplained uterine bleeding, endometrial hyperplasia or cancer and use of AIs.

Ospemifene, a selective estrogen receptor modulator (SERM), is approved for the treatment of dyspareunia due to GSM as a daily oral tablet. Studies have demonstrated improvement in GSM symptoms compared to placebo.[20]

Lasofoxifene, a SERM, and prasterone, a vaginal DHEA, are also being studied for their effects on GSM. Fractional carbon dioxide laser therapy popularly called “vaginal rejuvenation” is also being studied but not yet FDA approved.

Women with breast cancer and other gynecological malignancies are at an increased risk of VVA and associated symptoms. Endocrine chemotherapy, surgery, and/or radiation may induce profound changes at urogenital levels which have to be timely recognized in oncologic care.[21] Compounding the situation, the use of adjuvant endocrine therapy with Gonadotropin Releasing Hormone (GnRH) agonists, AIs, or SERMs (e.g., tamoxifen, raloxifen) has increased from 69.8% in 2004 to 82.4% in 2013 in women with hormone positive cancers.[22] Even though data regarding efficacy are limited, vaginal moisturizers and lubricants are considered the initial and mainstay treatment options for GSM for women with breast cancer.[6] The safety of local estrogen therapy, when nonpharmacologic and nonhormone therapies have failed in women with or at high risk of breast cancer, has not been definitely established, and recommendations for use remain controversial.[23]

GSM, though very common, does not receive the desired attention. Hence, it becomes a chronic condition which can compromise the quality of life of an otherwise healthy lady. It should therefore be proactively managed by healthcare providers to preserve urogenital and sexual health as long as possible through hormonal, nonhormonal, and lifestyle measures.



 
   References Top

1.
Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Maturitas 2014;79:349-54.  Back to cited text no. 1
    
2.
Robinson D, Cardozo LD. The role of estrogens in female lower urinary tract dysfunction. Urology 2003;62:45-51.  Back to cited text no. 2
    
3.
Nappi RE, Palacios S. Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric 2014;17:3-9.  Back to cited text no. 3
    
4.
Tan O, Bradshaw K, Carr BR. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: An up-to-date review. Menopause 2012;19:109-17.  Back to cited text no. 4
    
5.
Simon JA, Goldstein I, Kim NN, Davis SR, Kellogg-Spadt S, Lowenstein L, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International Society for the Study of Women's Sexual Health (ISSWSH) expert consensus panel review. Menopause 2018;25:837-47.  Back to cited text no. 5
    
6.
Management of symptomatic vulvovaginal atrophy: 2013 Position Statement of the North American Menopause Society. Menopause 2013;20:888-902.  Back to cited text no. 6
    
7.
Nappi RE, Palacios S, Panay N, Particco M, Krychman ML. Vulvar and vaginal atrophy in four European countries: Evidence from the European REVIVE survey. Climacteric 2016;19:188-97.  Back to cited text no. 7
    
8.
Nappi RE, Liekens G, Brandenburg U. Attitudes, perceptions and knowledge about the vagina: The International Vagina Dialogue Survey. Contraception 2006;73:493-500.  Back to cited text no. 8
    
9.
Nappi RE, Kokot-Kierepa M. Women's voices in the menopause: Results from an international survey on vaginal atrophy. Maturitas 2010;67:233-8.  Back to cited text no. 9
    
10.
Krychman M, Graham S, Bernick B, Mirkin S, Kingsberg SA. The women's EMPOWER survey: Women's knowledge and awareness of treatment options for vulvar and vaginal atrophy remains inadequate. J Sex Med 2017;14:425-33.  Back to cited text no. 10
    
11.
Sinha A, Ewies AA. Non-hormonal topical treatment of vulvovaginal atrophy: An up-to-date overview. Climacteric 2013;16:305-12.  Back to cited text no. 11
    
12.
Gupta N, Aggarwal M, Sinha R, Varun N. Study on prevalence and severity of urogenital complaints in postmenopausal women at a tertiary care hospital. J Midlife Health 2018;9:130-4.  Back to cited text no. 12
    
13.
Avis NE, Brockwell S, Randolph JF Jr., Shen S, Cain VS, Ory M, et al. Longitudinal changes in sexual functioning as women transition through menopause: Results from the study of women's health across the nation. Menopause 2009;16:442-52.  Back to cited text no. 13
    
14.
Pinkerton JV, Bushmakin AG, Komm BS, Abraham L. Relationship between changes in vulvar-vaginal atrophy and changes in sexual functioning. Maturitas 2017;100:57-63.  Back to cited text no. 14
    
15.
Gass ML, Cochrane BB, Larson JC, Manson JE, Barnabei VM, Brzyski RG, et al. Patterns and predictors of sexual activity among women in the Hormone Therapy Trials of the Women's Health Initiative. Menopause 2011;18:1160-71.  Back to cited text no. 15
    
16.
Kalogeraki A, Tamiolakis D, Relakis K, Karvelas K, Froudarakis G, Hassan E, et al. Cigarette smoking and vaginal atrophy in postmenopausal women.In Vivo 1996;10:597-600.  Back to cited text no. 16
    
17.
Reed SD, Newton KM, LaCroix AZ, Grothaus LC, Grieco VS, Ehrlich K, et al. Vaginal, endometrial, and reproductive hormone findings: Randomized, placebo-controlled trial of black cohosh, multibotanical herbs, and dietary soy for vasomotor symptoms: The herbal alternatives for menopause (HALT) study. Menopause 2008;15:51-8.  Back to cited text no. 17
    
18.
Bachmann G, Bouchard C, Hoppe D, Ranganath R, Altomare C, Vieweg A, et al. Efficacy and safety of low-dose regimens of conjugated estrogens cream administered vaginally. Menopause 2009;16:719-27.  Back to cited text no. 18
    
19.
Crandall CJ, Hovey KM, Andrews CA, Chlebowski RT, Stefanick ML, Lane DS, et al. Breast cancer, endometrial cancer, and cardiovascular events in participants who used vaginal estrogen in the Women's Health Initiative Observational Study. Menopause 2018;25:11-20.  Back to cited text no. 19
    
20.
Portman DJ, Bachmann GA, Simon JA; Ospemifene Study Group. Ospemifene, a novel selective estrogen receptor modulator for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Menopause 2013;20:623-30.  Back to cited text no. 20
    
21.
Faubion SS, Larkin LC, Stuenkel CA, Bachmann GA, Chism LA, Kagan R, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: Consensus recommendations from the North American Menopause Society and the International Society for the Study of Women's Sexual Health. Menopause 2018;25:596-608.  Back to cited text no. 21
    
22.
Daly B, Olopade OI, Hou N, Yao K, Winchester DJ, Huo D, et al. Evaluation of the quality of adjuvant endocrine therapy delivery for breast cancer care in the United States. JAMA Oncol 2017;3:928-35.  Back to cited text no. 22
    
23.
Faubion SS, Stuenkel CA, Chism LA, et al. Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: Consensus recommendations from the North American Menopause Society and The International Society for the Study of Women's Sexual Health. Menopause 2018;25:1-13.  Back to cited text no. 23
    




 

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