SYMPTOMS OF GSM

Genitourinary syndrome of the menopause (GSM) is an umbrella term to more accurately describe a range of vulvovaginal and lower urinary tract symptoms related predominately to low oestrogen levels. Signs of GSM include atrophic changes of the external and internal female genitalia with regression and thinning of the labia minora, retraction of the introitus, and prominence of the urethral meatus (Nappi et al, 2013). Symptoms may include genital dryness, painful intercourse, post-coital bleeding, burning, soreness, irritation and itching of the vulva or vagina, including urinary frequency and urgency (Portman and Gass, 2014). Some of these symptoms can lead to repeated oral antibiotic courses for suspected urinary tract infections (UTIs) and can have a significantly negative impact for women in terms of intimate relationships, sexual function and quality of life (Phillips et al, 2022).

Up to 80% of postmenopausal women report troublesome GSM symptoms and despite this, only 25% of women seek help and less than 10% start any treatment. (Nappi and Kokot-Kierepa, 2012). There are long-held beliefs and attitudes among women (including healthcare professionals) that GSM symptoms are a natural and unavoidable part of the ageing process (Sturdee and Panay, 2010). Embarrassment, anxiety and confusion continue to exist in both women and their healthcare providers leading to patients not presenting in the first place and clinician reluctance to prescribe.

Indeed, in a survey of healthcare professionals, 70% admitted that they never, or rarely asked about troublesome symptoms relating to vaginal dryness (Nappi and Kokot-Kierepa, 2012). Given the significant impact on women’s quality of life and evidence that only a minority of these symptomatic ladies present, it should be seen as an ideal opportunity to screen all menopausal women regardless of what they present with in primary care (Pitkin and British Menopause Society [BMS], 2018; Newson et al, 2021). It should also be noted that those with atypical presentations, such as irritability and behaviour changes, and those who may not be able to articulate symptoms, such as those with learning disabilities or dementia, may also go undetected (Martin et al, 2003; Newson et al, 2021).

TREATMENTS FOR GSM

Around 10–25% of women on systemic hormone replacement therapy (HRT) will also need local oestrogen, particularly for those with recurrent UTIs (Newson et al, 2021). Hormone treatment using low-dose vaginal oestrogen is still considered the gold standard and is safe and well tolerated (Pitsouni et al, 2018). However, many women remain reluctant to use them because of historical misguided concerns regarding long-term safety issues with hormone exposure, including breast cancer risks and potential side-effects. These apprehensions are further compounded by alarmist, inaccurate and outdated boxed warnings in oestrogen products (Pitsouni et al, 2018).

Local oestrogen can be started in the presence of a good clinical history and examination is not always necessary or possible during remote consultations. However, examination should be completed if there are any worrying symptoms, such as lumps or abnormal vaginal bleeding, to suggest underlying pathology, or when there is no response to treatment or symptoms worsen after starting treatment (Newson et al, 2021). If speculum examination can be performed, a cervical smear can also be offered to those who are eligible to save a further appointment. If, however, speculum insertion is uncomfortable or painful, the woman should be advised to return for screening a few months after gaining informed consent to start local oestrogen treatment.

 

Table 1: Summary of localised hormonal treatments
Depending on the vaginal product, initial treatment generally requires daily vaginal insertion or application for two to three weeks, then twice weekly for as long as needed. Treatment should be started promptly as the response can take time and will depend on the degree of atrophy at the time of presentation (Stuenkel et al, 2015). Vaginal epithelial absorption is greatest during the initial loading of local oestrogen when the tissue is most atrophic. Once the tissue quality has improved, absorption decreases and so smaller doses can be used indefinitely to maintain rigour in most preparations (Stuenkel et al, 2015).

Generally speaking, improvements are normally seen within three to four months, but the most severely affected women may take longer to respond. Treatment should be provided indefinitely with ongoing annual review (Newson et al, 2021). The only longer acting local oestrogen which does not require an initial loading schedule is the ESTRING vaginal ring (Pfizer), which is inserted high into the vagina and worn continually for three months (Table 1). Women should know that symptoms will likely recur on stopping treatment and that longterm use is safe.

Systemic absorption of vaginal estradiol has been found to be below the reference range in postmenopausal women (Santen et al, 2019). To further illustrate this point, using a vaginal oestrodial pessary twice weekly for one year equates to taking one dose of a 1mg oestrodial oral tablet (Hirschberg et al, 2021). There is therefore no need to protect the endometrium with progestogens (Hillard et al, 2017). Although local oestradiol preparations could cause minor problems, such as vaginal irritation and discharge, there is no evidence of an increased risk of cardiovascular disease, thromboembolism, colorectal cancer, endometrial cancer and primary or recurrent breast cancer (American College of Obstetricians and Gynecologists [ACOG], 2016; Laing et al, 2022).

Discouraging the use of soap or perfumed products is advisable and women can use simple emollients to both wash and moisturise with. Other local non-hormonal treatments, including vaginal lubricants and moisturisers (some of which are available on an NHS prescription), can be used on their own, or alongside, hormonal treatments (e.g. YES® and Sylk products).

Pelvic floor exercises and referral to physiotherapists who have specialised techniques to strengthen the pelvic floor and retrain the bladder can also be helpful (Women’s Health Concern, 2022). Other alternative treatments include vaginal dehydroepiandrosterone (DHEA), an oral selective oestrogen receptor modulator (ospemifene) and laser treatment. However, the evidence for these is less convincing and longer term data is lacking (Kearley-Shiers et al, 2022).

IMPACT ON SEXUALITY

GSM can also affect sexual desire, responsiveness and pleasure and can be associated with hypoactive sexual desire disorder (HSDD). Testosterone replacement has demonstrated improvements with these troublesome symptoms (Davis et al, 2019) and should be considered for menopausal women with low sexual desire if HRT alone is not effective (National Institute for Health and Care Excellence [NICE] 2015). Testosterone may also have beneficial effects on urinary tract function, as a survey found that women with low circulating serum testosterone were much more likely to have urinary incontinence (Kim and Kreydin, 2018).

Practice points

  • ● Be prepared to ask questions about GSM symptoms
  • ● Vaginal oestrogen is safe, cost-effective and can be used long term
  • ● Women can be given systemic HRT and local oestrogen together 
  • ● Vaginal lubricants and moisturisers can be prescribed and used alongside HRT.

References

American College of Obstetricians and Gynecologists (2016) ACOG Committee Opinion No. 659: The use of vaginal estrogen in women with a history of estrogen-dependent breast cancer. Obstet Gynecol 127(3): e93–e96. Reaffirmed 2020  

Davis SR, Barber R, Panay N (2019) Global consensus position statement on the use of testosterone therapy for women. Climacteric 22: 429–34  

Hillard T, Abernethy K, Hamoda H, et al (2017) Management of the Menopause. 6th edn. British Menopause Society  

Hirschberg AL, Bitzer J, Cano A, et al (2021) Topical estrogens and nonhormonal preparations for postmenopausal vulvovaginal atrophy: an EMAS clinical guide. Maturitas 148: 55–61  

Kearley-Shiers K, Holloway D, Rymer J, et al (2022) Intravaginal dehydroepiandrosterone for genitourinary symptoms of the menopause: Is the evidence sufficient? Post Reproductive Health 28(4): 237–43  

Kim MM; Kreydin EI (2018) The association of serum testosterone levels and urinary incontinence in women. J Urol 199: 522–7  

Laing AJ, Newson LN, Simon JA (2022) Individual benefits and risks of intravaginal estrogen and systemic testosterone in the management of women in the menopause, with a discussion of any associated risks for cancer development. Cancer J 28(3): 196–203  

Martin DM, Kakumani S, Martin MS, Cassidy G (2003) Learning disabilities and the menopause. J Br Menopause Soc 9(1): 22–6  

Nappi RE, Palacios S (2014) Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause. Climacteric 17(1): 3–9  

Nappi RE, Kingsberg S, Maamari R, et al (2013) The CLOSER (Clarifying Vaginal Atrophy’s Impact On Sex and Relationships) survey: implications of vaginal discomfort in postmenopausal women and in male partners. J Sex Med 10(9): 2232–41  

Nappi RE, Kokot-Kierepa M (2012) Vaginal Health: Insights, Views & Attitudes (VIVA) — results from an international survey. Climacteric 15(1): 36–44  

National Institute for Health and Care Excellence (2015) Menopause: diagnosis and management. NICE guideline [NG23];[updated 2019, Dec]. Available online: www.nice.org.uk/guidance/ng23   

Newson L, Kirby M, Stillwell S, et al (2021) Position statement for management of genitourinary syndrome of menopause. British Society for Sexual Medicine. Revised and updated in January 2023. Available online: https://balance-menopause.com/uploads/2021/10/GSM-BSSM-2023.pdf   

Phillips C, Hillard T, Salvatore S, Cardozo L, Toozs-Hobson P (2022) on behalf of the Royal College of Obstetricians and Gynaecologists. Laser treatment for genitourinary syndrome of menopause. BJOG 129: e89–e94 

Pitkin J, on behalf of the British Menopause Society medical advisory council (2018) BMS Consensus Statement: Urogenital atrophy. 2018. Available online: https://thebms.org.uk/publications/consensusstatements/urogenital-atrophy/    

Pitsouni E, Grigoriadis T, Douskos A, et al (2018) Efficacy of vaginal therapies alternative to vaginal estrogens on sexual function and orgasm of menopausal women: a systematic review and metanalysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 229: 45–56  

Portman DJ, Gass MLS (2014) 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. Menopause. J North Am Menopause Soc 21(10): 1063–68  

Santen RJ, Pinkerton JV, Liu JH, et al (2019) Symposium report. Workshop on normal reference ranges for estradiol in postmenopausal women. Menopause 27: 614–24  

Stuenkel CA, Davis SR, Gompel A, et al (2015) Treatment of symptoms of the menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 100(11): 3975–4011  

Sturdee DW, Panay N (2010) IMS Writing Group. Recommendations for the management of postmenopausal vaginal atrophy. Climacteric 13(6): 509–22  

Women’s Health Concern (2022) Urogenital Problems. Factsheet. Available online: www.womens-health-concern.org/wp-content/uploads/2022/12/23-WHC-FACTSHEET-UrogenitalProblems-NOV2022-B.pdf   


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