Genitourinary Syndrome of Menopause (GSM) – the ‘silent epidemic’

Conversations about the menopause have become very open, with women frankly discussing symptoms like hot flushes, brain fog and anxiety. Yet, symptoms related to the Genitourinary Syndrome of Menopause (GSM), which is a huge component of menopause, are frequently under-reported, under-recognized and undertreated. 

GSM, formerly known as vulvovaginal atrophy or atrophic vaginitis, describes the changes in the lower genital tract associated with menopause. It is caused by a decrease in oestrogen levels which leads to changes in the tissues of the vulva, vagina and urinary tract. Low oestrogen levels lead to reduced lubrication, and a reduction in collagen and tissue elasticity, and blood flow. The vaginal and urinary tissues become thinner, dryer, less elastic, more fragile. The muscles in the pelvic floor become weaker. The pH (acidity) of the vaginal secretions changes and the normal discharge becomes more alkaline, which can lead to irritation around the vulva and vagina.

These changes can result in a variety of bothersome symptoms:

• Vaginal dryness
• Vaginal itching and burning
• Painful sex
• Urinary symptoms, such as needing to urinate more frequently, urgency, burning on passing urine, stress incontinence
• Vaginal and urinary tract infections-changes in the vaginal environment can make it more susceptible to infections. Some women may experience recurrent urinary tract infections due to changes in the urinary tract tissues
• Vaginal bleeding- some women may experience light bleeding due to the capillaries in the vagina becoming so fragile.
• Sexual difficulties- the changes in the genital tissues, such as dryness and thinning, and the resulting discomfort, can have a significant negative impact on sexual function, including arousal and orgasm.

Unsurprisingly GSM often has a severe negative impact on a woman’s quality of life, social activity and sexual relationships. Studies have found that between 50-70% of postmenopausal women are symptomatic at least to some degree. Yet, women are frequently embarrassed to talk about these symptoms, or think that they are a normal part of ageing, and that nothing can be done about them. Likewise, clinicians frequently do not ask about them. However, this ‘silent epidemic’ does not need to be seen as an inevitable part of the aging process.

Without treatment GSM symptoms won’t improve and may progressively worsen. But with treatment GSM symptoms can be reversed and improved.

So how can we treat GSM?

Oestrogen replacement

Oestrogen replacement is gold standard. It is the most effective treatment for GSM. Oestrogen restores the vaginal and urinary tissues to how they were before menopause, which brings a significant relief from symptoms. It has also been shown to improve sexual function and reduce the risk of urinary tract infections.

Oestrogen can be given systemically as part of HRT, or it can be given as local treatment, vaginally.

Vaginal oestrogen may be used alone or in conjunction with HRT. Vaginal oestrogen can be given in the form of pessaries, creams or rings. Vaginal oestrogen is associated with minimal to no side effects when used as prescribed, as very little is absorbed into the blood stream, and it can be safely used by most women.

Vaginal moisturisers and lubricants

For women who cannot or do not want to use hormones, vaginal moisturisers, used regularly, can provide some relief from symptoms of vaginal dryness. Lubricants may be useful when having sexual intercourse.

Some women also find that hyaluronic acid vaginal gel or tablets help. Hyaluronic acid works by trapping water cells in tissues.

Lifestyle measures

Vulva hygiene is very important. It is advisable to avoid soap, shower gel, bubble baths and other irritants on the vulva as they can affect the healthy balance of bacteria, as well as the pH levels in the vagina, and can cause irritation. Emulsifying ointments should be used instead. They are simple moisturisers, which can be put directly on the skin and used instead of soap for washing or added to your bath.

Continuing to be sexually active may improve symptoms by improving blood flow which helps maintain healthy vaginal tissues. Some women find that using vaginal dilators helps.

Pelvic floor exercises and physiotherapy

They can help strengthen pelvic floor muscles and improve urinary symptoms and sexual pleasure.

Newer treatments

Laser treatments applied to the vagina have been developed in recent years. There isn’t enough scientific evidence so far on their effectiveness and safety and they are not widely used, but they may help some women with menopausal vaginal symptoms.

GSM adversely affects the lives of many women for many years, yet treatments are effective, and symptoms can be reversed. There is no need for women to suffer in silence.

Bojana Dragovic has 20 years’ experience as an NHS Consultant Physician in Sexual Health and HIV. She is a British Menopause Society accredited Menopause Specialist. Bojana is passionate about supporting and helping women through their menopause transition and beyond and improving their quality of life and long-term health.

References

• Angelou K, Grigoriadis T, Diakosavvas M, Zacharakis D, Athanasiou S. The Genitourinary Syndrome of Menopause: An Overview of the Recent Data. Cureus. 2020;12(4):e7586. Published 2020 Apr 8. doi:10.7759/cureus.7586
• Women’s Health Concern-Urogenital problems https://www.womens-health-concern.org/wp-content/uploads/2022/12/23-WHC-FACTSHEET-UrogenitalProblems-NOV2022-B.pdf
• Bhupathiraju SN, Grodstein F, Stampfer MJ, et al. Vaginal estrogen use and chronic disease risk in the Nurses’ Health Study. Menopause. 2018;26(6):603-610. doi:10.1097/GME.0000000000001284
• Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA) – results from an international survey. Climacteric. 2012; 15 (1): 36- 44.

Useful Resources

Women’s Health Concern: https://www.womens-health-concern.org/

Menopause Matters: https://menopausematters.co.uk