Genitourinary Syndrome of Menopause and Effective Treatments
Vaginal Atrophy- In the best sense the word “atrophy” means to waste away. In our worst connotation it means to shrivel, deteriorate or become a vestigial during evolution. Dear Lord, is this what we want to think of the vagina for almost half the women in menopause?
Certainly not, and yet it was not until 2014 when the International Society for the Study of Women’s Sexual Health (ISSWSH) and the North American Menopause Society (NAMS) came together to find a new medical term to describe the changes in the genital and urinary tract for women who have entered menopause and beyond—Genitourinary Syndrome of Menopause and GSM. Before this, there was just –atrophy. Is it a wonder that women have been so embarrassed to seek help for these natural changes that occur? If we don’t have a way to describe it, then the power of language tells us that it must not exist or perhaps it’s in your head.
But it’s not!!!
And for decades women have believed that there was nothing to be done for these changes or that , ‘suck it up buttercup” this is what happens and maybe painful sex or apareunia—no sex—is the way to live out your golden years after age 51 or 52. In fact any low estrogen state can result in GSM, which includes the postpartum state, lactation and the use of certain medications like aromatase inhibitors .
Now we have a term to describe the changes in the vulva, vagina, bladder, urinary tract, urethra due to the declining levels of estrogen that result from the retirement of your reproductive system. The symptoms that result due to the lack of estrogen and falling levels of androgens and resulting changes in the pH of the vagina and normal vaginal flora include but are not limited to , painful sex (dyspareunia), vaginal dryness, vaginal itching , urinary frequency, urinary urgency, frequent urinary tract infections, as well as potential architectural changes in the vulva.
These changes on exam can include a narrow vaginal opening, resorption of the inner lips of the vagina or labia minora, decrease in the fat pad and scant pubic hair. Internally, not only does the vaginal caliber changes, the cervix becomes difficult to access and the thinness of the skin of the vagina leads to bleeding in the vagina.
Remember that postmenopausal bleeding should always be evaluated!
In the postmenopausal period , these symptoms can get progressively worse and chronic over time and do not resolve without treatment.
Women often avoid intimacy due the changes and pain with sex that results.
With pain with sex, many women lose their libido and arousal and cannot climax leading to multiple forms of sexual dysfunction! Nowadays, we have many many options for treatment and depending on the patient, we can adapt our treatment to their needs and their ability to take medications.
I recommend all women utilize a vaginal moisturizer 2-3 days out of the week depending on severity. I like the hyaluronic acid based moisturizers because they not only provide comfort to the patient through moisture but also provide acidity to reduce the pH of the vagina. Vaginal lubricants, which can be water, silicone or oil based, can be utilized during and after intercourse as needed to provide comfort during times of intimacy.
The mainstay treatment for GSM has always been low dose vaginal estrogen.
There are creams such as Premarin and EStrace used 2-3 x a week. There are vaginal tablets that may be less messy for some women such as Vagifem, Yuvafem or Imvexxy. There is also a vaginal estrogen ring available for women with GSM. The low dose Estring is great for women given the amount that is released daily (7.5mcg) and is effective 90 days, so it works well for long term use.
Vaginal estrogen does not seem to increase risk of blood clots in the legs, venothromboembolic events. With appropriate discussion with your oncologist, if you are breast cancer survivor, many women experience harsh GSM symptoms and sometimes low dose Estrogen in the vagina could be warranted.
A newer vaginal insert known as intrarosa has been approved for GSM. It is dehydroepiandrosterone (DHEA) which is a prohormone for testosterone and estrogen. It is showing benefit if used daily in improving pain with sex, vaginal pH and discomfort. There is a local conversion of estradiol and testosterone but not a profound increase in systemic hormone levels. Many oncologists working with sexual medicine providers are using this in some breast cancer survivors but it should be considered on a case by case basis and based on a discussion with your physicians.
For those women who do not do well with vaginal inserts or creams, there is systemic pill known as ospemiphene, which is selective estrogen receptor modulator and has a positive effect on the vagina but not systemically. It is taken as a pill, 60mg daily.
Although somewhat controversial, there is much promise in laser technology , particularly CO2 laser ablative procedure for GSM via Mona Lisa Touch.
I do not like to advertise it as a vaginal rejuvenator but the studies have been promising on its impact on GSM. I have this machine in my office and offer it to patients who do not want to manage with the costs of estrogen or other meds daily or do not feel comfortable taking hormones. It works to resurface the vaginal tissue by activating heat shock proteins that increase and activate growth factors which in turn increases vascularity and collagen production and reduces the pH of the vagina.
For my patients with significant pain with sex, or “sandpaper sex” as my sexual medicine colleague Dr. Lauren Streicher calls it, I always recommend additional therapy. This could include pelvic floor therapy, biofeedback, a combination of estrogen and testosterone cream, vaginal dilators, sex therapy and possibly much more. You never know until you ask.
If you cannot find a doctor to help you navigate this process, please see the North American Menopause Society or the International Society for the Study of Women’s Sexual Health to find some certified providers or members vested in treating women with these conditions! Together we can work to live our best lives and improve our vulvo-vaginal health!