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What is Genitourinary Syndrome of Menopause?

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 of Genitourinary Syndrome of Menopause

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 of Genitourinary Syndrome of Menopause

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 of Genitourinary Syndrome of Menopause

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 of Genitourinary Syndrome of Menopause

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 of Genitourinary Syndrome of Menopause

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 over-the-counter treatment options, such as:

  • Vaginal moisturizers, such as K-Y Liquibeads, to restore moisture to the vaginal area and improve elasticity
  • Water-based lubricants, such as K-Y Jelly, 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 therapy comes in many forms and include:

  • Vaginal estrogen cream, such as Estrace, that is inserted directly into the vagina with an applicator
  • Vaginal estrogen suppositories (Imvexxy), which are low-dose estrogen suppositories inserted into the vaginal canal
  • Vaginal estrogen ring, such as Femring and Estring, 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.
  • Vaginal estrogen tablet, such as Vagifem, where a disposable applicator is used to place a vaginal estrogen tablet into the vagina

Ospemifene (Osphena): Another treatment option for GSM are 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.

Prasterone (Intrarosa): 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.

Lifestyle modifications: Increased sexual activity is advised for the maintenance of good vaginal muscle condition. There is a positive connection between sexual activity and maintenance of vaginal elasticity and flexibility as well as lubricative response to sexual stimulation. Cessation of smoking and limited alcohol intake is also advised to relieve symptoms, as well as regular physical exercises to strengthen vaginal muscles.


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