GENITOURINARY SYNDROME OF MENOPAUSE

Genitourinary syndrome of menopause (GSM) is one of the very common problems of menopause which is often ignored compared to hot flashes as women often suffer from it silently. It used to be called vulvo-vaginal atrophy, however at a consensual meeting of one of the menopause societies in 2013 it was renamed as GSM. GSM is more inclusive, as it includes all its symptoms related pelvic floor, urinary tract, vulva, vagina and sexual activity. This is a progressive condition and never improves. Initially about 50% of women suffer from it, but by the time they reach 70yrs of age, almost 70% suffer from it. All these problems are due to loss of oestrogens from the pelvic organs as they have a high concentration of oestrogen receptors.

As years go by there is less and less oestrogen after menopause. So these conditions progress over time and never improve. The symptoms are as follows:

1) Dry and burning vagina, suprapubic pain (central area just above the pubic bone)

2) Loss of fullness of the labia and the vulva, sparse hair

3) Loss of vaginal elasticity turgor, rugae and its length

4) Bladder problems such as frequency of urination,

stress and urgency incontinence and repeated bladder infections.

5) Weak pelvic floor, cystocele, rectocele and vaginal vault prolapse

6) Altered vaginal pH which becomes alkaline, this results in loss of bacteria called lactobacillus, which with the help of oestrogens and glycogen keeps the vagina acidic and clean. This process breaks down resulting, in vaginal infections already thin vagina, inflammation, fissures, often causing vaginal bleeding episodes, especially after sex.

7) All these changes lead to difficult sexual problems and very painful sex (dysparenuia).

8) Atrophy of the clitoris, along with failure of its stimulation and orgasm. This leads to personal psychosexual dissatisfaction.

9) Depressive episodes and poor quality of life

10) Increased vaginal fragility, ecchymosis, erythema and increased watery vaginal discharge

Besides the normal aging and menopause, there are many risk factors which can cause GSM. These include,

1) Surgical removal of both ovaries with the uterus

2)  Cancer treatment, chemotherapy or radiotherapy

3) Premature ovarian failure, some congenital conditions

4) Antidepressant drugs

5) Postpartum

6) No previous vaginal birth

7) Life style factors such as smoking and alcohol abuse

8) Infrequent sexual intercourse, vulvodynia, vaginismus, as the saying goes use it or lose it.

Women are very hesitant to discuss the problems of GSM to their care givers as they feel embarrassed although it is much better since it is called GSM in place of, vulvo-vaginal atrophy. To some extent it is much better if the care giver initiates the discussion on this line.  When a woman comes to us for menopausal symptoms we must always discuss the problems involving GSM. We should always ask her age, how long ago she had her last period, history of any operations, any cancer and subsequent treatment, urinary problems, bladder infections, sexual difficulties, heart disease, deep venous thrombosis and any other significant illness.

When we examine these women we must do a blood pressure and full general examination, pelvic examination can sometimes be difficult, as the labia minora is sometimes fused, however this can be easily separated gently with lubrication, often the vagina is very narrow and a normal 2 finger examination is not possible, you can use a small speculum. Always do rectal examinations as this can often give significant findings, try and do a paptest, vaginal pH, high vaginal swab and urine test for any infections. An ultrasound can be useful if the woman has a uterus and if you were unable to do a proper pelvic examination. Make a wet smear to exclude infections such as trichomonas which is a sexually transmitted infection. Menopausal women do not normally suffer from thrush as they do not have oestrogens unless they are diabetic or on oestrogen treatment. In these cases we need to exclude local infections, foreign bodies, cancer, skin conditions called leucoderma, lichen sclerosis(these are skin disorders in the area) and lupus which is an autoimmune disease.

Management of GSM

After arriving at a definite diagnosis of GSM the clinician has to make sure if a woman has any other symptoms particularly vasomotor symptoms; if that is the case the woman generally use oestrogens by whatever route they decide. Often just local lubrication or a moisturiser is required in mild cases of GSM. Lubrication is important at the time of intercourse, where as moisturisers lasts for 24 hours,these are watery, oily or silicone based.  The oily ones are no good if a woman uses condoms or a diaphragm, this should not be a problem at this age. If systemic hormones are not being used, local vaginal creams are available in various forms and dosage.  They come as creams or tablets, ovules and rings often with applicators. Your clinician should be able to prescribe these for you. In women who have had breast cancer they can be used, please do this in consultation with the doctor treating for breast cancer.

The other group of drugs used for this problems are called SERMS, meaning they are oestrogens but act differently on different organs. One such drug is Ospemifene. This is excellent for vaginal health. This rejuvenates the vagina and relieves dyspareunia. 

Ospemifene  does not stimulate the breast tissues ,it did not have  significant effects on cardiovascular system or deep venous  thrombosis, thus is a safe drug to be used for postmenopausal women with GSM ,particularly with severe dyspareunia. Its usefulness with bladder problems is not clear .Its safety in women with breast cancer and high risk for breast cancer needs to be further studied. Ospemifene is given orally in a dose of 60mg daily over one year. It acts like a oestrogen, vaginal moistness increases, the pH becomes acidic , vaginal elasticity improves , vaginal thickness improves , there are more mature cells  dyspareunia almost relieved.

Lasofoxifene is a newer SERM which has being tried recently in GSM and is useful for vaginal dryness and pH. It also helps with bone mineral density and a decrease in cardiovascular disease and stroke.

Vaginal dehydroepiandosterone(DHEA)

Daily vaginal application of DHEA cream helps with GSM. It improves the acidity, increases the maturation of vaginal thickness.

Side effects can be hot flushes and muscular pain. Less than 1% of woman showed endometrial thickening on ultrasound.  It can be used orally and continuously for up to one year. It helps more with vaginal pH and dryness. Bazedoxifene is another SERM for treatment of GSM but it contains conjugated oestrogens, hence it cannot be used for the treatment of GSM after breast cancer or in patients who have risk of thrombo-embolism.

Another treatment mentioned is oxytocin cream, it helps to some extent. 
Since 2014 fractional microablative (MonalisaTouch)laser treatment is the mainstay of treatment of GSM. It is available in most of the western world. 

There are side effects reported for women who undergo the laser treatment. These are mostly minor and may include itching, burning, redness, or swelling immediately following the procedure. 

A special laser tube is inserted into the vagina and it is gently brought down, no anaesthesia is required. It takes about 5minutes to do this. The laser activates the heat shock proteins which in turn activate growth factors. This in turn improves the vascularity, glycogen, collagen, extracellular matrix, vaginal papilla, and vaginal thickness. This solves most of the problems such as, sexual activity, dyspareunia, pain, burning, dysuria, ph decreases infections and quality of life improves. No preparation is required; women are advised not to have sex for few days .Three treatments are given at 4 to 6 weeks apart. Follow up is required each year. This is being studied further to study the long term side effects.

Another type of laser called Erbius (YAG) laser is being studied for GSM and urinary incontinence.

Another Laser for vulval problems is being tried in Italy.

This is a low frequency Dynamic quadripolar radiofrequency laser (DQR). It helps with the rearrangement of elastin fibres and collagen. It improves the sex satisfaction dysuria and incontinence. This is being studied with great enthusiasm.

Other treatments are lifestyle factors, weight, cigarettes, alcohol, frequent sex, use of vaginal dilators, vibrators, even masturbation and pelvic floor exercises. Sometimes surgical treatment may be necessary for pelvic floor prolapse, although researchers are experimenting with stem cells. Alternative treatments such as acupuncture and herbal remedies can be tried.

Conclusion

GSM is a very under diagnosed and under treated condition. It is estimated that by 2030 there will be 1 .2 Billion women in the world 50-70 % of these will suffer from GSM. The medical fraternity has too help them. One of the most important aspects is to educate them. We have to take special care for women who have had breast cancer or are at high risk for it. Local oestrogen therapy is the main stay for this.  Although SERMs are providing, good promise. Laser provides even bigger promise, but further studies are needed. We the care givers of these women should educate them, tell them what is on offer and make their lives happy