Genitourinary Syndrome of Menopause (GSM)
1Ng Beng Kwang, 1Phon Su Ee, 2Ho Choon Moy, 1Rahana Abd Rahman, 1Ani Amelia Zainuddin
1Department of Obstetrics & Gynaecology, UKM Medical Centre
2Obstetrics & Gynaecology, Pantai Hospital Cheras, Kuala Lumpur
As women age, the ovarian function declines, which is manifested by decreased oestrogen production. This hypoestrogenic state encompasses a conglomerate of symptoms, including vasomotor and genitourinary symptoms. Physiological menopause generally occurs around the age of 45 to 55 years, with the average age of 51. However, it can also occur earlier in pathological or iatrogenic conditions, such as primary ovarian insufficiency due to various causes, after chemotherapy or following surgical removal of the ovaries.
What is Genitourinary Syndrome of Menopause?
Genitourinary Syndrome of Menopause is a new terminology, used to describe a constellation of aggravating symptoms that affect the genitals, urinary system and sexual function due to a clinical state of hypoestrogenism, which concurs with the time of menopause. The term was previously known as atrophic vaginitis (AV) or vulvovaginal atrophy (VVA). The International Society for the Study of Women’s Sexual Health (ISSWSH) and the North American Menopause Society (NAMS) endorsed the new term “Genitourinary Syndrome of Menopause” (GSM) in 2014, because it is medically more accurate, all encompassing, and publicly more acceptable than “vulvovaginal atrophy”.
Why does it happen?
The female genital and lower urinary tracts share a common embryological origin. They share a common oestrogen receptor function, hence both are sensitive to the effects of female sex steroid hormones. Oestrogen is essential in keeping the vitality of the genitourinary system. Following menopause, the oestrogen level declines. The vagina shortens and loses its elasticity, and its epithelium becomes thin, dry and fragile. The vaginal acidity is altered, predisposing it to infections. As the vulva becomes atrophic, the labia majora and minora shrinks and contracts, exposing the underlying sensitive areas, making it more prone to chafing. The introitus is also retracted, and the urethral meatus becomes more prominent. Pelvic floor muscles become weaker, giving rise to urinary symptoms.
How common is GSM?
GSM is common condition, affecting more than 40% of women at midlife and beyond. Despite being a treatable medical condition, it is often underdiagnosed and undertreated. According to the Pan-Asian REVIVE study, which was a study on GSM in 5 Asian countries, found that only 21% had been clinically diagnosed with GSM and only 24% had ever used treatment for their symptoms. Among the reasons leading to the undertreatment of the condition, were:
- Lack of awareness
- Only 35% were aware of the GSM condition, most of whom first heard of GSM through their physician (32%).
- Misperception that GSM was a transient condition, hence hindering them from seeking treatment.
- Insensitivity of healthcare providers in addressing GSM symptoms
- Only 25% had discussed their GSM symptoms with a health-care provider (HCP), and such discussions were mostly patient-initiated (64%) rather than HCP-initiated (24%).
- Women were embarrassed to admit they have symptoms or see it as a taboo.
- Inappropriate treatment by attending healthcare practitioners.
- Reluctance of patients and healthcare professionals to commence on hormone replacement therapy (HRT) due to fear of its ‘side effects’.
What are the signs and symptoms of GSM?
Generally, the manifestations of GSM are divided into genital, urological and sexual symptoms. A summary of the manifestations of GSM is shown in the table below.
|Dryness||Frequency||Loss of libido|
|Irritation/ Burning sensation||Urgency||Dyspareunia|
|Itchiness||Nocturia||Loss of arousal|
|Abnormal vaginal discharge||Stress / urgency incontinence||Post coital bleeding|
|Redness||Dysuria||Lack of lubrication|
|Vaginal / pelvic pain||Urinary tract infection|
|Thinning of pubic hair|
How is GSM diagnosed?
GSM is a diagnosis of exclusion. Diagnosis can be made based on symptoms and physical findings once other conditions, such as infection, dermatitis (contact or allergic), dermatoses, and neuropathic conditions, have been ruled out.
Use of the Most Bothersome Symptom (MBS) approach aids in diagnosis and evaluation of treatment response. Itching, irritation, and dyspareunia are likely to be indicative of GSM. Combining the MBS with the physical exam is the most valid approach to diagnosis. Physical exam findings include:
- fragile vaginal wall epithelium with bleeding
- absence of vaginal wall rugae
- reduced vaginal wall elasticity
- reduced vaginal and cervical secretions
- vulvar atrophy
- vaginal stenosis and shortening
- stenosis of vaginal introitus
- retraction of urethral meatus
- associated pelvic organ prolapse
Apart from the MBS and physical findings, the vaginal maturation index (VMI) is a simple and inexpensive tool that can be utilised, to assist in the diagnosis of GSM. A vaginal pH can also be used in conjunction with the VMI for greater sensitivity. As GSM improves, the vaginal pH should become more acidic.
What are the treatments for GSM?
The primary goal of treating GSM is to relieve symptoms and improve quality of life. In general, management of GSM can be divided into non-pharmacological and pharmacological methods.
Non-pharmacological methods aim to reduce irritation to the genital area:
- Wear loose fitting, cotton underwear whenever possible. Limit time of wearing tight fitting undergarments and pants.
- Ensure the genital area is always kept clean and dry. Pat dry, as opposed to rubbing, after cleaning the genital area.
- Avoid douching and using harsh chemical products, such as hygiene wash, spray and soaps on the genital area. If required use clean water only.
- Wash undergarments using hypoallergenic products, and consider second rinsing of fabrics if needed.
- Avoid shaving of genital area.
- Cool washes with a dilute solution of bicarbonate of soda (2.5ml in 1L of water) or compresses for itching and mild discomfort.
The NAMS 2017 Hormone Therapy Position Statement Advisory Panel, lists locally absorbed oestrogen therapies as a first-line treatment for moderate-to-severe GSM symptoms. For mild symptoms, utilisation of non-hormonal lubricants and moisturisers are recommended.
If a patient has only genitourinary symptoms, systemic hormone therapy is not recommended due to the imposed risks of breast and endometrial cancer, stroke and deep vein thrombosis (DVT). Localized vaginal oestrogen therapy will suffice in most cases. Studies had revealed that all methods of low-dose estrogenic preparations of cream, vaginal tablet, and ring were equally and highly effective in relieving GSM symptoms and there is no additional risk of endometrial cancer. If there is any concern or contraindications for using oestrogen containing preparations, such as in cases of personal history of breast cancer, venous thrombosis or stroke, Ospemifene, a selective oestrogen receptor modulator is the alternative drug that can be used. Dehydroepiandrosterone (DHEA) is also another drug to be considered, if the patient has contraindication towards oestrogen usage. It is a hormone produced in the adrenal gland that is converted to oestradiol and/or testosterone in peripheral target cells. As showed in a recent systematic review, laser therapy for postmenopausal GSM appears promising. It may reduce the symptoms severity and improve quality of life. However, the evidence is low and evidence based modification of current practice cannot be suggested.
GSM is a chronic and progressive condition, that has significant impact on the quality of life of postmenopausal women. Fortunately, it is a treatable condition. Hence, timely diagnosis and adequate treatment is essential. Treatment of GSM aims to alleviate symptoms, and the options of management are based on severity of the symptoms. In mild condition, regular application of vaginal moisturiser and lubricant are recommended. For moderate to severe condition, locally absorbed oestrogen therapies remain as the first-line treatment. Newer alternatives for patients who are contraindicated to usage of oestrogen preparations include Ospemifene and DHEA.
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