Genitourinary Syndrome of Menopause: Causes, Symptoms, and Management

Introduction:

Genitourinary syndrome of menopause is a persisting condition associated with collapsed estrogen levels. Estrogen is a female hormone that is mostly produced by the ovary. Apart from ovaries, both adrenal glands, as well as certain fat cells, also contribute to estrogen production. It is influential in the functioning of the reproductive, cardiovascular, urinary, and musculoskeletal systems. Menopause is accompanied by a sudden estrogen level disruption, manifesting various symptoms.

What Is the Genitourinary Syndrome of Menopause?

All the genitourinary symptoms associated with menopause are collectively known as genitourinary syndrome of menopause (GSM). Menopause is the cessation of regular periods characterized by hormonal disproportion, which is reflected in various symptoms. However, GSM is also seen in premenopausal and postmenopausal females as they also develop a hormonal imbalance. Perimenopause refers to the stage immediately preceding menopause, and post-menopause refers to the stage succeeding menopause. The term genitourinary syndrome of menopause is relatively new and was put in place in 2014; until then, it was known by other names like vulvovaginal atrophy, atrophic vaginitis, and urogenital atrophy.

What Are the Causes of Genitourinary Syndrome of Menopause?

GSM is precipitated by an estrogen level dip associated with menopause. Estrogen supports the genitourinary system in numerous ways. However, certain females in the perimenopausal age group may also develop this syndrome under certain conditions:

1. Females suffering from primary ovarian insufficiency in which ovaries fail to function normally; hence ovarian hormone production will be compromised.

2. Females who have undergone surgical removal of the ovaries, technically known as oophorectomy.

3. Cancer treatment may significantly affect the hormonal regulation of the body and lead to unexplained estrogen level dip. In addition, chemotherapeutic drugs also come up with hormonal imbalances in cancer patients.

4. Hormonal imbalance is seen immediately after pregnancy and during the lactating stage could also result in GSM.

5. Certain drugs like Gonadotropin-releasing hormone agonists, Aromatase inhibitors can induce hormonal imbalance in reproductively active females.

6. Long-term withdrawal from sex could lead to hormonal disproportion.

What Are the Symptoms Associated With Genitourinary Syndrome of Menopause?

All the symptoms that are associated with GSM are the results of estrogen imbalance. Most of the symptoms manifest in the vulvovaginal and lower urinary tract areas. As age advances, these symptoms get worse.

• Dryness in the vagina is the hallmark symptom of GSM that distinguishes GSM from urinary tract infections.

• Burning or itching sensation in the vagina, creating discomfort to the patient.

• Penetrative sex becomes highly painful and is often accompanied by bleeding.

• Diminishing lubrication during sexual intercourse.

• The elasticity of the vagina that aids in sex will be compromised.

• Prone to urogenital infections.

• Significantly reduced sex drive and could harm sexual life.

• Reduced bladder tonicity is reflected in the inability to control the tendency for urination, resulting in frequent urination and urinary incontinence.

• The feeling of pressure or pain in and around the pelvic area.

• Discharge from the vagina.

• Prolapse of the vaginal vault and urethra.

How Is GSM Diagnosed?

Diagnosis of GSM does not require complex diagnostic tests and procedures. Instead, a detailed medical history followed by a pelvic examination is sufficient for the diagnosis. In addition, doctors may advise a vaginal pH evaluation test or a vaginal maturation index in certain instances to rule out some other closely resembling infection.

What Are the Risk Factors Associated With GSM?

• Smoking increases estrogen metabolism and enhances vaginal degeneration.

• Females who never had vaginal childbirth are more prone to develop GSM.

• Excessive alcohol consumption.

• Absence of physical activity.

• Early surgical removal of both ovaries.

Is Genitourinary Syndrome of Menopause Treatable?

Most people believe that GSM is not treatable as it is associated with aging. We cannot cure it permanently; however, prompt therapy can control the symptoms and discomfort to an extent. As the condition is highly symptomatic, controlling the symptoms could increase their quality of life. Treatment choice is largely based on the symptoms; hence, it varies from patient to patient. Doctors advise the treatment based on the medical history and physical examination. Treatment options include both hormonal as well as non-hormonal therapies.

1. Non-hormonal treatment modalities:

• Topical agents in the form of vaginal lubricants and vaginal moisturizers are prescribed to compensate for dryness and discomfort. Most doctors advise them as the first-line treatment. Vaginal moisturizers help maintain the vaginal pH in its optimum condition. Vaginal lubricants are advised during sex.

• Liquid Lidocaine compresses the vulvar vestibule and is advised for patients who cannot take hormonal replacement therapy, like breast cancer patients.

• Pelvic Floor Physical Therapy (PFPT) is advised for patients with bladder issues like the inability to control urination. In addition, patients having problems with sexual function can also benefit from pelvic floor physical therapy.

• Laser treatments are recently evolved treatment modalities for GSM in which micro ablative fractional CO2 laser and non-ablative photothermal vaginal erbium YAG enhances sexual functions.

• Dilation therapy to regain compromised vaginal elasticity.

• Complementary therapies include oral vitamin D, vaginal vitamin E, probiotics, and phytoestrogens.

2. Hormonal treatment modalities:

• Hormonal replacement therapies are the benchmark for treating highly symptomatic genitourinary syndrome of menopause as they manage the estrogen dip in GSM. Hormonal replacements can be systemic, oral, vaginal, transdermal, or subcutaneous.

• Vaginal hormonal therapies include intra-vaginal creams, rings, and tablets. They can be either estrogen or estradiol-releasing tablets or inserts, specifically in low concentrations. They are very effective in controlling the symptoms of GSM. Dehydroepiandrosterone (DHEA) is also advised in the form of vaginal inserts to enhance estrogen concentration.

• Selective estrogen receptor modulator (SERM) in oral tablet forms is an alternate option. Commonly administered SERM is Ospemifene.

• Hormone supplements can also be in the form of low-dose estrogen-releasing implants placed subcutaneously and patches or gel placed transdermally.

Is There Any Other Condition That Can Mimic GSM?

Few conditions that cause vaginal dryness and irritation mimic that of a GSM. But thorough medical history, pelvic examination, and laboratory findings will pave the way for proper diagnosis of the condition.

• Bacterial vaginosis, which is an overgrowth of the vaginal floor.

• Candidal infection of the vagina.

• Trichomonas infection, which is a sexually transmitted parasitic infection.

• Vaginismus, which is fear of some or all forms of vaginal penetration.

• Allergic reaction to harsh chemicals in the market labeled as personal hygiene products.

• Reaction to certain contraceptives.

Conclusion:

Genitourinary syndrome of menopause is a medical condition that can be symptomatically managed with proper treatment. However, in most cases, women are hesitant to come to a doctor for treatment, considering it is part of the aging process. In addition, pain and other discomfort associated with GSM significantly affect their quality of life. As sex becomes painful, they cannot attain sexual satisfaction. Impacts their sexual life badly if the partner cannot understand the situation, which questions their intimacy. Hence it is important to maintain proper communication with the partner. Consulting a doctor and taking prompt treatment can improve the quality of life.